Documentation Requirements
What Medicare reviewers look for when they request records. Work the checklist before you respond to an additional documentation request (ADR) — every item below is reproduced from the payer's own published document, so you can point to it by name in an appeal.
0 of 11 requirements checked
Check each item off as you confirm it is in the record you are submitting.
Evaluation and management (E/M) services
For dates of service on or after January 1, 2023.
- Number and complexity of problems addressed
- The amount and/or complexity of data to be reviewed and analyzed
- Risk of complications and/or morbidity or mortality of patient management
Source: Checklist: Evaluation and management (E/M) services — First Coast Service Options, April 30, 2026
This checklist was created as an aid to assist providers. It 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.