Checklist: Chemotherapy, drugs, biologicals, and injection services
This checklist is intended to provide health care providers with a reference for use when billing chemotherapy, drugs, biologicals, and injection services. Health care providers retain responsibility to submit complete and accurate documentation.
| Check |
Documentation description |
|---|---|
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Documentation is for the correct beneficiary and date of service. |
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Documentation is complete, legible, signed and dated by the Physician or Clinician. |
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Documentation must support all billed CPT codes. |
| Documentation includes physician’s order for date(s) of service when medication(s) were administered, to include the medication name, dosage, frequency, and method of administration |
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| Documentation to support medical necessity including office/progress notes, history and physical, etc |
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| Evaluation & management/counseling notes: medication administration record and/or infusion therapy notes for dates of service include the medication name, dosage, method of administration, and start/stop times for infusions (when applicable). |
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| Documentation to support the amount of drugs or biologicals discarded (single use packaging) for the relevant beneficiary (when applicable). |
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| Nursing notes and/or clinic notes. |
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| Documentation for the procedures, operative reports, and anesthesia reports (when applicable) |
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| If billing incident to services, the documentation supports appropriate supervision (billing physician is present in the office suite during the performance of procedure). |
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Documentation meets criteria specified in NCDs and LCDs (if applicable) |
| Any Advanced Beneficiary Notice of Noncoverage (ABN) issued to the beneficiary for each date of service and each specific service an ABN was issued |
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| Beneficiary signed and dated Authorization to Bill Medicare form is now required. |
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 CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.