Checklist: ESRD documentation
This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for ESRD services. Health care providers retain responsibility to submit complete and accurate documentation.
| Check |
Documentation description |
|---|---|
| Documentation is legible. |
|
| Signed / authenticated order by an authorized CMS prescribing provider which notes frequency of dialysis treatment and method of dialysis. |
|
| Signed physician’s orders including pertinent dialysis protocols / standing orders and changes in treatment for patient’s care. |
|
| Note: dialysis orders are considered valid for one year. |
|
| Assure all orders are signed timely (within 30 days) by the physician - date all signatures, include ledger or key with electronic records where initials were used for signatures, include signature log when appropriate. |
|
| History and physical exam information supporting the diagnosis and treatment, along with relevant trends or status changes. |
|
| Treatment/dialysis flow sheet documentation for DOS billed which must include patient pre / post treatment weight, method of access, treatment start / end time, treatment record and patient assessment. |
|
| All treatment / flow sheets are complete with date, times off and on machine and administration of medications. |
|
| Separate order and rationale for any extra dialysis treatments. |
|
| Orders for medications or lab work not billed in the bundle payment. |
|
| Test results to support medical necessity and results of all services billed. |
|
| Records for all dates of service that appear on the claim. |
|
| Record of all medications administered. |
|
| All progress notes including physician, nurse and other multi-disciplines including regular physician evaluations documenting efficacy of treatment. |
|
| Documentation does not include vague descriptions (e.g., “patient remains stable”). |
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.