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Checklist: Musculoskeletal system and connective tissue or procedures

This checklist is intended to provide health care providers with a reference for use when responding to additional documentation requests for musculoskeletal system and connective tissue procedures (DRG 515, 516 and 517). It is not intended to replace the published guidelines. Health care providers retain responsibility to submit complete and accurate documentation. 

Check

 Documentation description
  Documentation is for the correct beneficiary and date of service.
  Documentation is complete, legible, signed and dated by the physician or clinician.
  Physician orders.
 

History and physical including documentation to support the diagnosis billed.

  • Diagnoses/reason for the procedure performed.
  • Evaluation/process of arriving at the diagnosis of in an individual muscle(s) or muscle group.
  • Presenting clinical symptoms that led to the diagnosis.
  • Noninvasive medical management that has been unsuccessful at treating the underlying symptom(s) or condition(s).
  Legible progress notes including physician, nurse, dietician, and other multi-disciplines.
  All diagnostic and laboratory reports.
  Anesthesia reports.
  Surgical procedure reports.
  Consult reports.
  Medication administration record.
  Any other clinical records that support the medical necessity of the service billed.
 

Revision of previous procedure:

  • Diagnoses / reason for the procedure performed.

  • Evaluation of the affected muscle(s), joint, or tissue group.

  • Presenting clinical symptoms.

  • Documentation of failed noninvasive medical management.
  • Documentation supporting all billed services
  Itemized bill.
  Advanced Beneficiary Notice (ABN), if applicable

 

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.