What Documents are Needed?

• OASIS form for the dates of service in question
• Face-to-face encounter document
• Current home health certification and plan of care (appropriately signed and dated by doctor and nurse; and/or the receipt date from agency as needed)
• Any additional MD orders for the date of service in question, signed and dated by the doctor
• Therapy initial evaluation, reevaluations, and treatment visit notes for previous month and date of service in question
• Skilled nursing 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

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.

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

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

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

Clinic and Therapeutic Services

• Clinical 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 (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

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

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

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 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

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

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

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

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

Gastrointestinal Services

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

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

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

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

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

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

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

Intraveneous Therapy

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

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

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

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

Oncology and Therapeutic Radiology

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

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

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

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

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

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

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

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

The following are examples of services for which you may be experiencing denials and are unclear of what documentation is needed when requesting an appeal. Many of the services on this list are associated with frequency parameters or diagnosis requirements. This list should be used as a guide to assist your office with the documentation required to process your appeal request as it relates to each of these specialties.

Anesthesia

• Pre-anesthesia record
• Anesthesia record
• Operative report
• Radiology report
• Reason for which anesthesia was rendered for a radiology service

Biofeedback

• Progress/office notes
• History and physical

Blepharoplasty

• Operative report
• Visual field study
• Original photo or slide

Cardiac Rehabilitation Services

• EKG tracing and documentation of medical necessity/treatment plan

Chiropractic Services

• Progress/office notes for entire year of service
• Documentation of medical necessity

Concurrent Care

• Records for entire hospital course including admission summary, progress notes, and order sheets

Cosmetic Surgery/Procedures of Questionable Current Usefulness (POQCU)

• Documentation of medical necessity
• Operative report
• Admission summary
• History and physical

Excision of Lesions

• Operative report
• Surgical pathology report

Extensive/Unusual Services (Modifier 22)

• Include office records
• Test results
• Operative notes
• Hospital records to substantiate the extenuating circumstance
• This information should be included when the original claim is submitted. If this information is not included, processing of your claim will be delayed, or the claim will be denied.

Holter Monitoring

• History and physical or consultation notes
• Test results for date of service in question
• Test results for any prior or subsequent dates of service

Laboratory Testing

• Lab report for date of service in question
• Lab report for any previous and subsequent dates of service, if any, for the same test

MRI and CAT Scan (Global Service) for Same Anatomical Area of the Body on Same Day

• MRI and CAT scan reports

Nerve Conduction Velocity (NCV) Studies, Electromyography Studies

• Patient history
• NCV worksheet or report of results of studies
• Reports for any prior and subsequent studies, if any

Noninvasive Arterial and/or Vascular Diagnostic Studies

Documentation that would support the necessity of this testing includes, but is not limited to:

• Order or intent to order, for each study
• Relevant medical history
• Physical examination
• Pertinent diagnostic studies/results

Other pertinent information (not an all-inclusive list):

• Discharge notes
• Consultations
• Medication records
• Therapy treatment plan and notes
• Discharge summary and notes
• Emergency room visits
• Physician progress notes

Physiatry

• Admission summary
• Progress notes
• Order sheets
• Reassessment

Radiology

• Radiology report with provider, date and time notated

Reduced Service (Modifier 52)

• Include office records
• Test results
• Operative notes
• Hospital records to substantiate the reason for reporting a reduced service

Note: This information should be included when the original claim is submitted. If this information is not included, processing of your claim will be delayed or the claim will be denied.

Surgery/Cosurgery/Team Surgery/Assistant Surgery

• Operative report for each surgeon

Transthoracic Echocardiography

• Radiology report
• Office notes
• History and physical
• Documentation of medical necessity

Two Inpatient E/M Visits or Inpatient E/M Visit and Consult on Same Day

• Records for hospital course including progress/visit/critical care notes
• Consult report
• Admission summary
• Discharge summary

Not all requests will require you to submit documentation such as hospital records, procedure reports, lab results, etc. A large majority of requests result from information that was omitted from the claim when it was originally submitted for processing. In those situations, a reopening may be requested and/or performed by the MAC to correct the omission or clerical error. Examples include (but are not limited to) the following:

• Submission of an incorrect ICD-10-CM diagnosis code
• Omission of a modifier 78 or 79 to indicate related or unrelated surgery within the global period of another surgical procedure
• Omission of a modifier 59 to indicate a distinct procedural service reported on the same day or during the same session as another service.