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January 24, 2013 - Revised 07.02.13

Ambulatory Surgery Centers (ASCs): Providing Documentation

As a reminder, CGS or other Medicare contractors may request medical record documentation to support the medical necessity for services based on Local Coverage Determination (LCD) requirements and/or to determine the correct payment. Medical records are designed (and expected) to record significant facts, findings, and observations about an individual's health history, including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high-quality care.

In addition, the medical record facilitates:

  • The ability of the physician and other health care professionals to evaluate and plan the patient's immediate treatment and to monitor their health care over time.
  • Communication and continuity of care between physicians and other health care professionals involved in the patient's care.
  • Accurate and timely claims review and payment.
  • Appropriate utilization review and quality of care evaluations.

An appropriately documented medical record can reduce many of the "hassles" associated with claims processing and serves as a legal document to validate the care provided.

At a minimum (this list is not all-inclusive), medical records for each encounter should include:

  1. The date of service(s)
  2. The patient's name
  3. Treating physician's progress/office notes stating the reason for the service(s)
  4. Copies of diagnostic tests to support the medical necessity of the service

All entries to the medical record should be dated and authenticated by the physician/provider signature.

While we realize that your facility did not order the services you are providing, we would like to remind you that when two separate providers collaborate to provide quality patient care the obligation of providing, obtaining, and maintaining documentation is not the exclusive responsibility of one or the other provider. Both are responsible for documenting and submitting documentation to receive Medicare payment. Providing documentation is a basic prerequisite for ALL Medicare providers. The treating physician should provide the facility with documentation supporting medical necessity prior to or at the time the service is rendered. This will also satisfy the ASC's requirement to have a preoperative evaluation present in the patient's file prior to services being rendered.

Section 4317 of the Balanced Budget Act (BBA: SEC.4317, REQUIREMENT TO FURNISH DIAGNOSTIC INFORMATION) addresses this situation:

When a test is "…ordered by a physician or a practitioner specified in subsection (b)(18)(C), but furnished by another entity, if the Secretary (or fiscal agent of the Secretary) requires the entity furnishing the item or service to provide diagnostic or other medical information in order for payment to be made to the entity, the physician or practitioner shall provide that information to the entity at the time that the item or service is ordered by the physician or practitioner."

If you do not respond to requests from CGS for supporting medical records, your claim may be denied. If the service has already been paid, CGS may request repayment of funds.


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