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What to keep in your patient files

Your patient files are an important part of doing accurate and legitimate billing to Medicare. There are certain items that should be kept in each patient's file from the very first visit, so that they are easily referenced at any time. If Medicare requests documentation from you and you cannot provide it to them, be prepared to refund money to them, since the claim will be denied as not medically necessary.

In order to help you organize your files, here are some examples of documents that should be in each patient's file:

  • Copies of the front and back of the patient's insurance card(s)
  • Assignment of Benefits (if billing assigned)
  • Original doctor's orders
  • Original completed CMN's
  • Delivery tickets (sometimes called "proof of delivery") containing detailed information about the item(s) delivered and the date of delivery
  • Pick up tickets containing detailed information about the item(s) picked up and the date of pick up
  • Extra documentation from doctor's notes, hospital notes, etc.
  • Rent/purchase letters
  • Advanced Beneficiary Notices (for items that are believed not to be covered by Medicare)
  • Detailed descriptions of products that the patient has received
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