Documentation Requirements
The patient’s medical record should include but is not limited to:
• The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
• Relevant medical history
• Results of pertinent tests/procedures
• Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)
• Performance of the study in a stoke center
Effective 12/12/2021 please append computed tomography cerebral perfusion analysis identified with CPT 0042T with the KX modifier to attest the CTP analysis was performed in a certified stroke center.
If the service is provided in the emergency room (POS 23) the ER must be part of the certified stroke center to qualify for coverage.
The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient and indicate the reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes will
be returned.
The documentation of the study requires a formal written report, with clear identifying demographics, the name of the interpreting provider, the reason for the tests, an interpretive report and copies of images. The computerized image reconstruction data should also be maintained.
Documentation must be available to Medicare upon request.
