Checklist: Transitional Care Management services documentation
This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for Transitional Care Management. 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. | |
|
At a minimum, document this information in the patient’s medical record:
Medical Decision Making (MDM) refers to establishing diagnoses, assessing the status of a condition, and selecting a management option, is defined by 3 elements:
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| Documentation to support any applicable modifiers billed with the E/M service | |
| Documentation to support “incident to” guidelines (if applicable) | |
| Any additional documentation to support medical necessity or any applicable policy guidelines for the services billed | |
| Documentation includes an advanced beneficiary notice (ABN) of non-coverage was provided (if applicable and 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 the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.