Checklist: Percutaneous intracardiac procedures
This checklist is being provided as a tool to assist providers when responding to medical record documentation requests for percutaneous intracardiac procedures (DRG 273 and 274).
It is the responsibility of the practitioner who provided the services to ensure the correct submission of documentation.
| Check |
Documentation description |
|---|---|
| Name of beneficiary and date of service in all documentation. |
|
| Admission orders. |
|
| Inpatient certification. |
|
| Anesthesia / sedation record. |
|
| Signed, timed and dated physician’s medical orders for each day of service. |
|
| History and physical. |
|
| Legible physician progress notes. |
|
| Procedure report. |
|
| Anesthesia report. |
|
| Two-midnight benchmark. |
|
| Medication administration record. |
|
| Summary of departmental medical records. |
|
| All diagnostics and laboratory reports, as applicable. |
|
| Surgical procedure reports. |
|
| Discharge Summary. |
|
| Signed advanced beneficiary notice of noncoverage (ABN). |
|
| Signature log or physician’s attestation for any missing signatures. |
|
| Any other documentation a provider deems necessary to support medical necessity of services billed, as well as documentation specifically requested in the letter. |
|
| Outpatient visit / progress notes detailing prior treatment or test results. |
|
|
Prior-to documentation requirements:
|
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.