Fillable 175804 Checklist EM documentation

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175804 Checklist EM documentation

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03/01/2020
Medicare pays physicians based on diagnostic and procedure codes derived from medical documentation. Proper medical record
documentation is critical to providing patients with quality care as well as receiving accurate and timely reimbursement for furnished
services. Complete medical record documentation also assists physicians and other health care professionals in evaluating and
planning a patient's immediate treatment and overall health care. It is the physician's responsibility to ensure documentation reflects
the services furnished and the codes selected reflect those services accurately.
This checklist is an aid to assist providers when responding to medical record documentation requests pertaining to evaluation and
management services.
It is the responsibility of the practitioner who provided the services to ensure the correct submission of documentation.
Note: To print and include this checklist with your medical documentation, click the print button at the end of this form.
The following principles should be followed when submitting medical documentation.
Complete and legible medical record documentation should be submitted
Should include specific documentation that may have been requested
Submit medical records for the date(s) of service(s) on the claim under review
Ensure the medical record submitted supports the service(s) that was (were) ordered and/or rendered
To support the level of service (code), include documentation to address the following:
Chief complaint
History
• If history is taken by ancillary staff, ensure the billing practitioner indicates this was reviewed
Physical exam
Medical
decision-making
Any additional documentation that may support medical necessity of the level of service(s) billed
Medical re
cords shoul
d j
ustify that the service was medically reasonable and necessary for the diagnosis/treatment of the injury or
illness, and should include:
Physician's progress notes
Initial history and physical
Physician's orders
Procedure notes
Assessment, clinical impression, or diagnosis
Checklist: Evaluation and management documentation
03/01/2020
X-ray, diagnostic test and laboratory results
Medical plan of care
Legible signatures of professionals providing services
Documentation based on counseling or coordination of care to include:
Total time (e.g., critical care, start/stop time)
Amount, or percent, of time involved in counseling or coordination of care
Description of the discussion
Note: Time alone does not determine the level of service. Documentation must support the level of service billed.
Providers should refer to CMS' official documentation guidelines for evaluation and management services at
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html for additional
information.
Disclaimer: This checklist was created as a tool to assist providers and is not intended as a replacement for the published 1995 and
1997 Evaluation and Management Documentation Guidelines. It is the responsibility of the provider of services to ensure the correct,
complete, and thorough submission of documentation.
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175804 Checklist EM documentation

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Completed 14 March 2020

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