Progress Notes and Templates

3.3.2.1.1 - Progress Notes and Templates (Rev. 13008; Issued: 12-18-24; Effective: 01-17-25; Implementation: 01-17-25) 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.