Checklist: Drugs, biologicals, and injection services documentation

Documentation is for the correct beneficiary and date of service.

Documentation is complete, legible, signed, and dated by the physician or clinician

Documentation includes physician’s order for date(s) of service when medication(s) were administered, to include the medication name, dosage, frequency, and method of administration.

Medication administration record for dates of service include the medication name, dosage, method of administration, and start/stop times for infusions (when applicable).

Documentation to support the amount of drugs or biologicals discarded (single use packaging) for the relevant beneficiary (when applicable).

Medical necessity supported by the medical record (e.g., office/progress notes, history and physical, laboratory test results, etc.)

Documentation for the procedures, operative reports, and anesthesia reports (when applicable).

Documentation to support "incident to" guidelines (if applicable), that includes evidence of billing provider's presence in the office suite, initial assessment, and ongoing participation/management of the patient's care.

Documentation meets criteria specified in NCDs and JH LCDs and JL LCDs.

Evidence that an advanced beneficiary notice of non-coverage (ABN) was provided to the beneficiary, if applicable.