CMS Pub. 100-08, ch. 3, § 3.3.2.1.1

A. Definitions

For the purposes of Section 3.3.2.1.1, the following definitions apply:

1. "Progress Notes" -- visit notes, encounter notes, Evaluation and Management

documentation, office notes, face-to-face evaluation notes or any other type of record of

the services provided by a physician or other licensed/certified medical professional

(LCMP) in the medical record. Progress notes may be in any form or format, hardcopy

or electronic.

2. "Template" -- a tool/instrument/interface that assists in documenting a progress note.

Templates may be paper or electronic.

Electronic records may involve any type of interface including but not limited to:

simple electronic documents,

sophisticated graphical user interfaces (GUIs) with clinical decision and documentation

support prompts, or

electronic pen capture devices.

3. “Licensed/Certified Medical Professional (LCMP)” – Medical professional

licensed or certified to practice in the state in which services are rendered. For the

purposes of documenting DMEPOS items, the physician or LCMP must not have a

financial relationship with the DMEPOS supplier.

B. Guidelines Regarding Which Documents Review Contractors Will Consider

The review contractor shall consider all medical record entries made by physicians and

LCMPs. See PIM 3.3.2.5 regarding consideration of Amendments, Corrections and

Delayed Entries in Medical Documentation.

The amount of necessary clinical information needed to demonstrate that all coverage and

coding requirements are met will vary depending on the item/service. See the applicable

National and Local Coverage Determination for further details.

The CMS does not prohibit the use of templates to facilitate record-keeping. CMS also

does not endorse or approve any particular templates except for the clinical templates it

publishes on its website. A physician/LCMP may choose any template to assist in

documenting medical information. Contractors shall consider information captured in

templates when conducting medical review.

Some templates provide limited options and/or space for the collection of information

such as by using “check boxes,” predefined answers, limited space to enter information,

etc. CMS discourages the use of such templates. Claim review experience shows that

that limited space templates often fail to capture sufficient detailed clinical information to

demonstrate that all coverage and coding requirements are met.

Physician/LCMPs should be aware that templates designed to gather selected information

focused primarily for reimbursement purposes are often insufficient to demonstrate that

all coverage and coding requirements are met. This is often because these documents

generally do not provide sufficient information to adequately show that the medical

necessity criteria for the item/service are met.

If a physician/LCMP chooses to use a template during the patient visit, CMS encourages

them to select one that allows for a full and complete collection of information to

demonstrate that the applicable coverage and coding criteria are met.

Certificates of Medical Necessity (CMN), DME Information Forms (DIF), supplier

prepared statements and physician attestations by themselves do NOT provide sufficient

documentation of medical necessity, even if signed by the signed by the ordering

physician.. See PIM §5.7 for additional information on documentation.

C. Financial Liability

The physician/LCMP should be aware that inadequate medical record documentation can

lead to a financial liability for the Beneficiary and/or Supplier, should the reviewer

determine that a claim is not supported.

In addition, the physician/LCMP should be aware that when ordering an item or service

that will be furnished by another entity, Section 1842(p)(4) of the Social Security Act

requires that adequate documentation supporting medical necessity be provided to the

entity at the time that the item or service is ordered. Physicians/LCMPs who fail submit

documentation upon a supplier's request may trigger increased MAC or RAC review of

the physician/LCMP's evaluation and management services.