Checklist: Outpatient hospital services documentation
This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for outpatient hospital services. It is not intended to replace the published guidelines. Health care providers retain responsibility to submit complete and accurate documentation.
| Check |
Documentation description |
|---|---|
| Documentation is for the correct beneficiary. |
|
| Documentation is for the correct date(s) of service. |
|
| Documentation contains a valid and legible signature, which follows CMS Signature Guidelines for Medical Review Purpose. |
|
| Documentation contains a valid physician’s order/referral or documentation to support intent for services performed. |
|
| Documentation supports a medically reasonable and necessary outpatient hospital service(s) that includes relevant documentation (e.g., history and physical examination, progress notes, treatment log, treatment plan of care, laboratory/diagnostic testing results, assessments, certifications, medication administration record, outpatient services final report, etc.). |
|
| Documentation includes an advanced beneficiary notice of non-coverage was provided (if applicable and required). |
|
| Any additional documentation to support medical necessity or any applicable policy guidelines for the services billed. |
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.