CMS-1500 Initiative Medical Narrative Requirements
Most Subsequent Narrative Reports should include documentation to support a medical re-evaluation of the patient's condition in response to the plan of care. Medical re-evaluation should be consistent with the General Guideline Principles (A.1, A.3, A.4, A.5, and A.8) of the Medical Treatment Guidelines (MTG), which start on page 1 of each of the MTGs. Please see Medical Treatment Guidelines on the Board's website.
Subsequent Narrative Reports should include the following:
- Rendering Provider's Name
Work Status Re-evaluation
- Is the patient working? If yes, provide the date(s) the patient:
- Resumed limited work of any kind
- Resumed full work
- If no, can the patient return to usual work activities as indicated?
- Are there any work limitations? (If so, explain and quantify, including the anticipated duration of the limitations)
- Return to work plan
Temporary Impairment Re-evaluation
- What is the percentage (0-100%) of temporary impairment?
- Describe findings and explain how impairment percentage was determined.
- Anticipated duration, if temporary impairment.
Doctor's Opinion (Based on this examination) - Causation
- Indicate if, in your opinion, the incident that the patient described was, the competent medical cause of this injury/illness.
- Indicate if the patient's complaints are consistent with their history of the injury/illness.
- Indicate if the patient's history of the injury/illness is consistent with the objective findings or if it is not applicable at this time.
History
- Interval changes in patient's symptoms or condition
- Review of status and impact of treatment on symptoms and function
- Review of medications including impact on symptoms and function
Objective Findings/Clinical Evaluation
- Physical examination (describe all relevant findings indicating any changes from prior examination according to History Taking and Physical Examination sections found in each Medical Treatment Guideline and per standard clinical practice for non-MTG injuries)
- Results of interval diagnostic tests, imaging studies and/or procedure(s) performed
- Diagnostic procedure(s)/test(s) performed during the visit
- Treatment rendered at time of exam, if any
Diagnosis(es)/Re-Assessment
- Clear identification of diagnosis(es), including differential diagnosis (i.e., not a listing of ICD or CPT billing codes)
- Report should include the assessment of function (whether there has been functional improvement and re-evaluation of the current treatment)
- Early recognition of patients with delayed recovery (pain and functional limitations that persist beyond the anticipated time of healing and recovery)
Plan of Care
- Proposed treatment and treatment goals (include type of treatment, frequency, anticipated duration of treatment and re-evaluation timeframe)
- Assess for delayed recovery and treat as indicated (per NAP MTG recommendations)
- Medications (prescription and over-the-counter drugs) prescribed for the injury/illness:
- Name, dose, frequency
- Identify discontinued medication(s) and/or changed dosage(s), including reason(s) for any changes
- Any work restrictions that may result from these medications
- Diagnostic test(s) ordered and indication(s)
- Referrals/consultations requested and indication(s)
- Assistive devices prescribed
- Re-evaluation of prognosis for recovery
- Follow-up appointment(s)