Subscribe to eNews Contact us

Checklist: Aftercare, musculoskeletal system and connective tissue

This checklist is being provided as a tool to assist providers when responding to medical record documentation requests for aftercare, musculoskeletal system and connective tissue (DRG 559, 560 and 561) services.

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.
 

Inpatient certification:

  • Signed and dated by a physician prior to discharge
  • Reason for inpatient admission
  • Estimated and/or actual hospital time
  • Progress notes support the reason for admission and explain current treatment. plans
  • Post-hospital care plans
  • Valid inpatient admission order
 

Admission order:

  • Includes specific language such as “admit to inpatient,” “admit to inpatient services,” or similar
  • Written order

Verbal order:

  • Includes specific language such as “admit to inpatient,” “admit to inpatient services,” or similar
  • Identity of the ordering physician/practitioner
  • Countersigned and dated by a physician/practitioner
  • Written at or before the time of the inpatient admission
  • Authenticated prior to discharge
 

Two-midnight benchmark:

  • Include all outpatient services time
  • Observation
  • Emergency department
  • Operating room
  • Other treatment areas
 

Exceptions or unforeseen circumstances:

  • Patient’s death
  • Patient transferred to another facility
  • Patient left against medical advice (AMA)
  • Unexpected recovery is clearly documented in medical record
  • Other
  Treatment or wound care notes
  Therapy records
  Weekly team meetings, notes and signatures of all involved (Case management, SW, MD/NPP, ST, OT, PT, etc.).
  Case management notes for discharge and/or insurance approvals.
  Signed, timed, and dated physician orders for each day of care/service.
  History and physical.
  Legible physician progress notes.
  All diagnostic and laboratory reports, as applicable.
  Surgical procedure reports.
  Anesthesia reports.
  Medication administration record.
  Nurses' notes.
  Ambulance run sheet.
  Discharge summary.
  Signature log or physician’s attestation for any missing signatures.
  Signed advanced beneficiary notice of noncoverage (ABN).
  Signed health insurance notice of non-coverage (HINN).
  Any other clinical records that support the medical necessity of the service billed.
  Any other documentation a provider deems necessary to support medical necessity of services billed, as well as documentation specifically requested in the letter.

 

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.