Checklist: Drugs and Biologicals
This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for Drugs and Biologicals. Health care providers retain responsibility to submit complete and accurate documentation.
| Check |
Documentation description |
|---|---|
| Documentation is for the correct beneficiary and date of service. |
|
| Documentation is complete, legible, signed and dated by the physician or clinician. |
|
| 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. |
|
| Medication administration record for dates of service include the medication name, dosage, method of administration, and start / stop times for infusions (when applicable). |
|
| Documentation to support the amount of drugs or biologicals discarded (single use packaging) for the relevant beneficiary (when applicable). |
|
| Medical necessity supported by the medical record (e.g., office / progress notes, history and physical, laboratory test results, etc.). |
|
| Documentation for the procedures, operative reports and anesthesia reports (when applicable). |
|
| Documentation meets criteria specified in National Coverage Determinations (NCDs) and Local Coverage Determination JN LCD provide link to LCD landing page for search criteria. |
|
| Evidence that an Advanced Beneficiary Notice of Non-coverage (ABN) was provided to the beneficiary. |
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.