Documentation needed for Inpatient Acute Facility (IAF) Services
• Please be sure documentation submitted is legible.
• Please submit records for all dates of service on the claim.
• Please ensure the medical records submitted provide proof the service(s) was ordered and rendered. Also, ensure the medical records provide justification supporting medical necessity for the service by submission of the following documentation:
o Hospital history and physical.
o Progress notes.
o Nurse’s notes.
o Disposition/discharge notes.
o Hospital discharge summary.
o Consultation reports.
o Medication administration records.
o Procedure notes.
o Treatment records.
o Physician's order/intent.
o Diagnostic test results/reports (including imaging reports).
o Observation orders and progress notes for each day.
o Emergency room records.
o Perioperative record.
o Intraoperative record.
o Operative reports.
o Recovery room record.
o Rehabilitation records.
o Anesthesia records.
o Authorized provider order.
o Lab/pathology report.
o Full detailed itemized bill indicating revenue code.
o Signatures/credentials of professionals providing services.
o Coding query form (if applicable) and all applicable therapy records.
o Any other documentation a provider deems necessary to support medical necessity of services billed, as well as documentation specifically requested in the Additional Documentation Request (ADR) letter.
• Please be sure documentation submitted is legible.
• Please submit records for all dates of service on the claim.
• Please ensure the medical records submitted provide proof the service(s) was ordered and rendered. Also, ensure the medical records provide justification supporting medical necessity for the service by submission of the following documentation:
o Hospital history and physical.
o Progress notes.
o Nurse’s notes.
o Disposition/discharge notes.
o Hospital discharge summary.
o Consultation reports.
o Medication administration records.
o Procedure notes.
o Treatment records.
o Physician's order/intent.
o Diagnostic test results/reports (including imaging reports).
o Observation orders and progress notes for each day.
o Emergency room records.
o Perioperative record.
o Intraoperative record.
o Operative reports.
o Recovery room record.
o Rehabilitation records.
o Anesthesia records.
o Authorized provider order.
o Lab/pathology report.
o Full detailed itemized bill indicating revenue code.
o Signatures/credentials of professionals providing services.
o Coding query form (if applicable) and all applicable therapy records.
o Any other documentation a provider deems necessary to support medical necessity of services billed, as well as documentation specifically requested in the Additional Documentation Request (ADR) letter.
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