CurrentCareSource GeorgiaPolicy MP-AD-1243

Medical Record Documentation Standards for Practitioners

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Defines required medical record documentation practices and standards that support medical necessity, coding, billing, and delivery of care for practitioners serving CareSource Marketplace members; applies across the listed marketplaces and provider network.

Policy Summary

PayerCareSource Georgia

PolicyMedical Record Documentation Standards for Practitioners

Policy CodePolicy MP-AD-1243

Change TypeAdministrative update — no material coverage changes

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review Date

Key ActionDocument services contemporaneously with date of service, include signature/credentials, and record timed service minutes or start/stop times when billing time-based CPT codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24+documentation items

24h / 14dtiming best practice

Includes CMNDME rules

MHPAEAparity note

Documentation Requirements to Support Coverage

Documentation criteria

Required documentation elements and practices that must be present in the medical record to support services billed and meet policy standards.

ALL of the following

Each member has an individual medical record; each page includes member name and date of service; entries are legible.

ALL of the following

Entries include date of service, signature (handwritten or electronic) with date and credentials of practitioner; signatures must be legible or validated; stamped signatures permitted only with documented physical disability per CMS rules.

ALL of the following

Documentation indicates the services billed were the services provided; CPT/modifiers/place of service codes must be appropriate and note reflects location of service.
For timed CPT services, document total timed minutes and/or start and stop time.
For group services, document member presence (or member-specific start/stop time if not present for full session), relationships/credentials of individuals present, and number of participants.

ALL of the following

Documentation includes a problem list of significant medical and behavioral conditions.
Content must show the specific needs of the member for each encounter; duplication of another note is not acceptable.

ALL of the following

Paper records
- Changes are clearly visible; white-out is not used; single line through entry labeled with error, initialed, and dated.
Electronic records
- Amendment, correction, or delayed entry is identified and the record reliably shows original content, modified content, and the date and person modifying the record.

ALL of the following

Documentation should be written within 24 hours of the clinical or therapeutic activity and signed and dated within 14 days (best practice).

ALL of the following

Documentation must support the specific E/M requirements for the billed level of service per CPT (time, medical decision making, complexity).
Complexity examples
- Self-limited or minor problems; stable chronic conditions; acute uncomplicated illness or injury; undiagnosed new problem with uncertain prognosis; chronic illnesses with severe exacerbation, progression, or side effects of treatment.

ALL of the following

Consent forms (consent to treatment, refusal, withdrawal, authorization for release of information) are maintained in the record with signature and date.
Referral documentation supports rationale, identifies specialty referred to, and demonstrates coordination of referrals and any physician review or collaboration notes.

ALL of the following

Documentation supports rationale for tests; an order is present; how results will guide treatment is evident; physician review of results is documented; timely follow-up with member is evident.

ALL of the following

When appropriate, include age-appropriate immunization record, evidence that preventive screenings/services are offered, completed risk assessments (eg, substance use, suicide, depression), and crisis/safety plan as appropriate.

ALL of the following

Detailed written order must include member name; item description/HCPCS/brand/model; prescribing practitioner's NPI; ordering practitioner's signature and date; duration of use; frequency/quantity for supplies; Certificate of Medical Necessity (CMN) if required or prescription with diagnoses if CMN not required; information demonstrating medical necessity; any changes in treatment plan; and proof of delivery.
Refill requests must be documented contemporaneously (written document from member or contemporaneous written record of phone contact), must occur before shipment, and retrospective attestations are not sufficient; refill record must include member name/authorized representative, item description, and date of request.

ALL of the following

Proof of delivery must document member name and delivery address; item description/HCPCS/brand/model; quantities delivered; date delivered; member or designee receipt signature with date and relationship; supplier signature and date; and for orthotics/prosthetics a member initial attesting satisfaction and training on use and care. Third-party shipping tracking or postage-paid return invoice is acceptable when shipped.

ALL of the following

When services are provided based on a physician's verbal orders, a nurse or other qualified practitioner must document the orders in the clinical record and sign, date, and time them; verbal orders must be followed up with written orders; suppliers must maintain the physician's written order to support medical necessity for post-payment review.

ALL of the following

Custom item documentation must show the item was uniquely constructed or substantially modified for the member, include physician description and orders, and evidence that the item cannot be grouped with another for pricing purposes.

ALL of the following

Deliberate falsification (eg, creating records when requested, back-dating, post-dating, writing over, adding to existing documentation except as allowed for amendments/late entries/corrections) is a felony and is handled seriously; legally amended corrections prior to claims submission will be considered, but records changed following payment determinations will be evaluated based on the original record.

Coding and Time-Based Service Documentation

CPT documentation supportmixed

CPT	Documentation must support CPT code selection including timed services, group services, appropriate modifiers and place of service.

Timed-service documentation

Timed-service requirementWhen CPT is time-based, the medical record must document the total number of timed minutes and/or the start and stop time alongside the CPT code and type of treatment.

Group service timingFor group-based CPT codes, document member presence; if not present for the full session, record the member-specific start and stop time.

Supporting elementsDocumentation must show the services billed were provided and include CPT/modifiers/place of service appropriate to the service and provider.

Record-level identifiersEach page of the record must include member name and date of service to link timed entries to the correct encounter.

Authorization, Payment, and Administrative Guidance

Note

Check Evidence of Coverage for authorization and payment

Administrative policy statements alone do not guarantee that a service is authorized or will be paid. Providers must check the member’s plan contract (Evidence of Coverage) for coverage terms and authorization requirements; if the Administrative Policy Statement conflicts with the plan contract, the plan contract (Evidence of Coverage) controls.

Defined Terms

Valid Signature

DefinitionA signature may be handwritten or electronic and must be legible or validated (e.g., compared to a signature log or attestation).

Stamped signaturesStamped signatures are permitted only if the practitioner has a physical disability and can demonstrate inability to sign to a CMS contractor.

Signature elementsEntries must include signature, date, and credentials of the practitioner on each relevant entry.

Certificate of Medical Necessity (CMN)

DefinitionCertificate of Medical Necessity (CMN): a written statement by a practitioner attesting that a particular item or service is medically necessary for an individual.

Use with DMECMNs are required where noted for DME and must accompany orders that document medical necessity for the item/service.

Order requirementsPrescribing documentation (e.g., DME orders) must include practitioner signature and date; CMN serves as the practitioner attestation of necessity.

Policy Summary

PayerCareSource Georgia

PolicyMedical Record Documentation Standards for Practitioners

Policy CodePolicy MP-AD-1243

Change TypeAdministrative update — no material coverage changes

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review Date

Key ActionDocument services contemporaneously with date of service, include signature/credentials, and record timed service minutes or start/stop times when billing time-based CPT codes.

SourceLink

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Medical Record Documentation Standards for Practitioners

Customize your policy alerts

Sign up for CareSource Georgia Policy MP-AD-1243 alerts

Get alerted when Policy MP-AD-1243 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Documentation Requirements to Support Coverage

Documentation criteria

Required documentation elements and practices that must be present in the medical record to support services billed and meet policy standards.

ALL of the following

Each member has an individual medical record; each page includes member name and date of service; entries are legible.

ALL of the following

Entries include date of service, signature (handwritten or electronic) with date and credentials of practitioner; signatures must be legible or validated; stamped signatures permitted only with documented physical disability per CMS rules.

ALL of the following

Documentation indicates the services billed were the services provided; CPT/modifiers/place of service codes must be appropriate and note reflects location of service.
For timed CPT services, document total timed minutes and/or start and stop time.
For group services, document member presence (or member-specific start/stop time if not present for full session), relationships/credentials of individuals present, and number of participants.

ALL of the following

Documentation includes a problem list of significant medical and behavioral conditions.
Content must show the specific needs of the member for each encounter; duplication of another note is not acceptable.

ALL of the following

Paper records
- Changes are clearly visible; white-out is not used; single line through entry labeled with error, initialed, and dated.
Electronic records
- Amendment, correction, or delayed entry is identified and the record reliably shows original content, modified content, and the date and person modifying the record.

ALL of the following

Documentation should be written within 24 hours of the clinical or therapeutic activity and signed and dated within 14 days (best practice).

ALL of the following

Documentation must support the specific E/M requirements for the billed level of service per CPT (time, medical decision making, complexity).
Complexity examples
- Self-limited or minor problems; stable chronic conditions; acute uncomplicated illness or injury; undiagnosed new problem with uncertain prognosis; chronic illnesses with severe exacerbation, progression, or side effects of treatment.

ALL of the following

Consent forms (consent to treatment, refusal, withdrawal, authorization for release of information) are maintained in the record with signature and date.
Referral documentation supports rationale, identifies specialty referred to, and demonstrates coordination of referrals and any physician review or collaboration notes.

ALL of the following

Documentation supports rationale for tests; an order is present; how results will guide treatment is evident; physician review of results is documented; timely follow-up with member is evident.

ALL of the following

When appropriate, include age-appropriate immunization record, evidence that preventive screenings/services are offered, completed risk assessments (eg, substance use, suicide, depression), and crisis/safety plan as appropriate.

ALL of the following

Detailed written order must include member name; item description/HCPCS/brand/model; prescribing practitioner's NPI; ordering practitioner's signature and date; duration of use; frequency/quantity for supplies; Certificate of Medical Necessity (CMN) if required or prescription with diagnoses if CMN not required; information demonstrating medical necessity; any changes in treatment plan; and proof of delivery.
Refill requests must be documented contemporaneously (written document from member or contemporaneous written record of phone contact), must occur before shipment, and retrospective attestations are not sufficient; refill record must include member name/authorized representative, item description, and date of request.

ALL of the following

Proof of delivery must document member name and delivery address; item description/HCPCS/brand/model; quantities delivered; date delivered; member or designee receipt signature with date and relationship; supplier signature and date; and for orthotics/prosthetics a member initial attesting satisfaction and training on use and care. Third-party shipping tracking or postage-paid return invoice is acceptable when shipped.

ALL of the following

When services are provided based on a physician's verbal orders, a nurse or other qualified practitioner must document the orders in the clinical record and sign, date, and time them; verbal orders must be followed up with written orders; suppliers must maintain the physician's written order to support medical necessity for post-payment review.

ALL of the following

Custom item documentation must show the item was uniquely constructed or substantially modified for the member, include physician description and orders, and evidence that the item cannot be grouped with another for pricing purposes.

ALL of the following

Deliberate falsification (eg, creating records when requested, back-dating, post-dating, writing over, adding to existing documentation except as allowed for amendments/late entries/corrections) is a felony and is handled seriously; legally amended corrections prior to claims submission will be considered, but records changed following payment determinations will be evaluated based on the original record.

Coding and Time-Based Service Documentation

CPT documentation supportmixed

CPT	Documentation must support CPT code selection including timed services, group services, appropriate modifiers and place of service.

Timed-service documentation

Timed-service requirementWhen CPT is time-based, the medical record must document the total number of timed minutes and/or the start and stop time alongside the CPT code and type of treatment.

Group service timingFor group-based CPT codes, document member presence; if not present for the full session, record the member-specific start and stop time.

Supporting elementsDocumentation must show the services billed were provided and include CPT/modifiers/place of service appropriate to the service and provider.

Record-level identifiersEach page of the record must include member name and date of service to link timed entries to the correct encounter.

Authorization, Payment, and Administrative Guidance

Note

Check Evidence of Coverage for authorization and payment

Defined Terms

Valid Signature

DefinitionA signature may be handwritten or electronic and must be legible or validated (e.g., compared to a signature log or attestation).

Stamped signaturesStamped signatures are permitted only if the practitioner has a physical disability and can demonstrate inability to sign to a CMS contractor.

Signature elementsEntries must include signature, date, and credentials of the practitioner on each relevant entry.

Certificate of Medical Necessity (CMN)

DefinitionCertificate of Medical Necessity (CMN): a written statement by a practitioner attesting that a particular item or service is medically necessary for an individual.

Use with DMECMNs are required where noted for DME and must accompany orders that document medical necessity for the item/service.

Order requirementsPrescribing documentation (e.g., DME orders) must include practitioner signature and date; CMN serves as the practitioner attestation of necessity.