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Checklist: Evaluation and management (E/M) services documentation

This checklist is intended to provide health care providers with a reference for use when responding to additional  documentation requests for E/M services (on or after January 1, 2023, for office/outpatient services and on or after January 1, 2023, for all other services). Health care providers retain responsibility to submit complete and accurate documentation. Additional tools and interactive score sheets are available to assist you on our website under our Evaluation and Management section.

Check Documentation description

 

 Documentation is for the correct beneficiary.

 

 Documentation is for the correct date(s) of service.

 

 Documentation contains a valid and legible signature, which follows CMS Signature Guidelines for Medical Review Purposes

 

 Documentation supports that a face-to-face visit occurred.

 

 Documentation supports medically reasonable and necessary E/M service as outlined in CMS IOM, Pub. 100-04, Claims Processing Manual, Chapter 12, Section 30.6.

 

If billing service based on medical decision making, all relevant documentation that supports the level of service billed (e.g., office and/or progress notes, physician's orders and intent, emergency room records, consultations/procedure reports, radiology/diagnostic tests, EKG, lab, and pathology results, etc.):

  • Number and complexity of problems addressed
  • The amount and/or complexity of data to be reviewed and analyzed
  • Risk of complications and/or morbidity or mortality of patient management

 

 If billing service based on time (if applicable), documentation to support time spent performing E/M service.

 

 Documentation to support any applicable modifiers billed with the E/M service.

 

 Documentation to support "incident to" guidelines (if applicable), that includes evidence of the billing provider's presence in the office suite and prior, ongoing participation in patient care.

 

 Documentation includes an advanced beneficiary notice of non-coverage was provided (if applicable and required).

 

 Any additional documentation to support medical necessity or any applicable policy guidelines for the services billed.

 

Disclaimer
This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.