| Providers in AR, CO, LA, MS, NM, OK, TX, Indian Health & Veteran Affairs | |
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This checklist is intended to provide healthcare providers with a reference for use when responding to medical documentation requests for IPPE services. Healthcare providers retain responsibility to submit complete and accurate documentation.
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Documentation description |
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Documentation is for the correct date of service, correct beneficiary, and contains a valid, legible signature. |
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Documentation supports that a face-to-face visit occurred. |
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Documentation supports review of the beneficiary’s medical and social history. At minimum the following information must be collected and documented within the medical record: Past medical and surgical history. Current medications and supplements. Family history. History of alcohol, tobacco, and illicit drug use. Diet. Physical activities. |
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Documentation supports review of the beneficiary’s potential risk factors for depression and other mood disorders (utilizing an appropriate screening instrument). |
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Documentation supports review of the beneficiary’s functional ability and level of safety (utilizing appropriate screening questions or nationally recognized standard questionnaires) that includes at a minimum the following areas: Activities of daily living. Fall risk. Hearing impairment. Home safety. |
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Documentation supports a physical examination with the following: Height, weight, body mass index and blood pressure. Visual acuity screen. |
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Documentation supports discussion of end of life planning and any documents if beneficiary agrees. |
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Documentation supports evidence of beneficiary education, counseling and referrals based on the required IPPE elements. | 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 CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.
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