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Checklist: Endovascular cardiac valve replacement and supplement procedures

This checklist is being provided as a tool to assist providers when responding to medical record documentation requests for endovascular cardiac valve replacement and supplement procedures (DRG 266 and 267).

It is the responsibility of the practitioner who provided the services to ensure the correct submission of documentation. 

Check Documentation description
  Any Advanced Beneficiary Notice of Non-coverage (ABN) issued to the beneficiary for each date of service and each specific service an ABN was issued.
  Documentation to support all codes billed.
  Anesthesia record and/or sedation record.
  Certification / recertification by physician.
  Certified plan of care by physician.
  Diagnostic test results / reports, including imaging reports.
  Documentation of minutes billed.
  Evaluation & management / counseling notes.
  History and physical (PCP, other physicians related to treatment to support medical necessity of procedure).
  History and physical.
  Implant log.
  Initial evaluation for therapy services.
  Intra‐operative record.
  Peri‐operative record.
  Medication administration records.
  Nurses' notes.
  Observation orders and progress notes.
  Operative reports and procedure notes.
  Pathology report.
  Physician order for therapy.
  Physician orders or intent to order for the dates of service billed.
  Physician / nonphysician practitioner (NPP) progress notes.
  Plan of care (may be part of evaluation).
  Psychosocial evaluation.
  Recovery room record.
  Reevaluations, when they have been performed.
  For electronic health records, send a copy of the electronic signature policy and procedures that describe how notes and orders are signed and dated.
  Emergency room records.
  Discharge summary / discharge notes.
  Clinic / office visit notes.
  Consultation reports.
 

NCD Transcatheter Aortic Valve Replacement (TAVR) 20.32 DRG 266/267

The patient (preoperatively and postoperatively) is under the care of a heart team: a cohesive, multi‐disciplinary, team of medical professionals. The heart team concept embodies collaboration and dedication across medical specialties to offer optimal patient‐centered care.

The heart team includes the following:

  • Cardiac surgeon and an interventional cardiologist experienced in the care and treatment of aortic stenosis who have:
    • Independently examined the patient face‐to‐face, evaluated the patient’s suitability for surgical aortic valve replacement (SAVR), TAVR or medical or palliative therapy
  • Documented and made available to the other heart team members the rationale for their clinical judgment
  • Providers from other physician groups as well as advanced patient practitioners, nurses, research personnel and administrators

The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the intra‐operative technical aspects of TAVR.
 

Before you send:

  • Check for signatures on notes or other medical record documentation:
    • If the signature(s) are missing or illegible, send a signature attestation
    • If the signature(s) are illegible, you can also send a signature log

 

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.