What are Medicare documentation requirements?
You should write clear and comprehensive information in each patient's records detailing the physician/NPP referral or order, the services and procedures performed, and the follow-up provided to the referring physician. Chapter 15 of the Medicare Benefit Policy Manual [PDF] has specific instructions for documentation in section 80.3 - Audiological Diagnostic Testing. They are:
Documenting for Audiological Tests. The reason for the test should be documented either on the order, and/on the audiological evaluation report, and/or in the patient's medical record. Examples of appropriate reasons include but are not limited to:
Reevaluation to follow-up changes in hearing, tinnitus or balance that may be caused for example, but not limited to otosclerosis, atelectatic tympanic membrane, tymposclerosis, cholesteatoma, resolving middle ear infection, Meniere's disease, sudden idiopathic sensorineural hearing loss, autoimmune inner ear disease, acoustic neuroma, demyelinating diseases, ototoxicity secondary to medications, genetic, vascular and viral conditions. Screening tests are not payable, but failure of a screening test may be an appropriate reason for diagnostic audiological tests
The medical record shall identify the name and professional identity of the person who ordered the evaluation and the person who actually performed the service. When the medical record is subject to medical review, it is necessary that the contractor determine that the service qualifies as an audiological diagnostic test that requires the skills of an audiologist. A technician must meet qualifications determined by the Medicare contractor to whom the claim is billed. At a minimum, the qualifications must include the requirements of any applicable State or local laws, and successful completion of a curriculum including both classroom training and supervised clinical experience in administration of the audiological service.
If a technician performs the technical component of a service that does not require the skills of an audiologist, the physician supervisor shall provide and document the physician's professional component of the service including, e.g., clinical decision making, and other active participation in the delivery of the service. Direct supervision rules apply to the physician for the technical component, requiring them to be in the facility and accessible. This participation may also be billed as evaluation and management code or as part of other billed services.
Documentation should also include a section describing the procedures that were completed and their outcomes; a section on clinical assessment of the findings; recommendations; signature; and date of service.
The "other diagnostic tests" benefit requires an order from a physician, or, where allowed by State and local law, by a non-physician practitioner. See section 80.6 of this chapter for policies concerning orders for diagnostic tests. The reason for the test should be documented either on the order, on the audiological evaluation report, or in the patient's medical record.
Examples of appropriate reasons include but are not limited to:
There are other things to consider besides the guidance in §80.3. In the final rule for the 2010 Medicare Physician Fee Schedule, CMS cautioned audiologists on calculating time attributed to the five timed audiology evaluation codes when it accepted the professional component relative value units (RVUs) for these codes in the 2009 fee schedule. CMS stressed that activities such as counseling, establishment of interventional goals, or evaluating potential for remediation are not included as diagnostic tests, and that time spent on these activities should not be included in billing for:
Documentation should also include a section describing the procedures that were completed and their outcomes; a section on clinical assessment of the findings; recommendations; signature; and date of service. An acronym to keep in mind is the SOAP note - Subjective findings, Objective findings, Assessment, Plan.
CMS has a document related to appropriate documentation on its Medicare Learning Network [PDF] website.