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Checklist: Musculoskeletal system and connective tissue or procedures

This checklist is being provided as a tool to assist providers when responding to medical record documentation requests for other musculoskeletal system and connective tissue OR procedures (DRG 515, 516 and 517).

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

Check Documentation description
  Please submit a mandatory advanced beneficiary notice (ABN) if issued.
  Admission and discharge summary.
  Physician orders.
  History and physical including documentation to support the diagnosis billed.
  All progress notes including physician, nurse, dietician, and other multi-disciplines.
  All diagnostic and laboratory reports, as applicable.
  Anesthesia reports.
  Signature log or physician’s attestation for any missing signatures.
  Legible physician progress notes.
  Operative / procedure reports.
  Consult reports.
  Documentation to support all services billed.
  Itemized bill.
  Any other documentation a provider deems necessary to support medical necessity of services billed, as well as documentation specifically requested in the letter.
  Documentation is for the correct beneficiary.
  Documentation is for the correct date of service.
  Documentation contains a valid and legible signature.
 

Documentation that includes a procedure note with the following information, if applicable: 

  • Description of the procedure.
  Documentation to support the treatment.
  Include a beneficiary waiver of liability in the submitted documentation, if applicable.
 

Documentation of a detailed history and examination that includes:

  • Diagnoses / reason for the procedure performed.
  • Evaluation / process of arriving at the diagnosis of in an individual muscle(s) or muscle group.
  • Presenting clinical symptoms that led to the diagnosis.
  • Noninvasive medical management that has been unsuccessful at treating the underlying symptom(s) or condition(s).

 

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.