Pre-Submission Documentation Review: A 25-Point Checklist Before Records Go to an Auditor

Introduction

Once records leave your organization in response to an Additional Documentation Request (ADR), audit, or record request, you generally cannot take them back. Reviewers make decisions based on what they receive by the deadline. If an order is missing, a signature is illegible, records belong to the wrong date of service, or key documentation from a referring practitioner was never obtained, the claim may be denied even though the service was appropriate.

A pre-submission documentation review is a final quality check performed before records are sent. It confirms that the right records are included, that they meet coverage and documentation requirements, and that the packet is complete and organized. It is not an opportunity to change the record. It is an opportunity to make sure that everything that legitimately exists in the record is found, included, and presented clearly.

This article provides a 25-point pre-submission checklist organized into six areas, explains how to perform the review, who should do it, what to do when gaps are found, and how to use review results to improve. It is educational and does not replace professional advice.

Why Pre-Submission Review Matters

CMS has consistently reported that insufficient documentation is one of the leading causes of Medicare fee-for-service improper payments. CMS's MLN fact sheet on medical record documentation lists common insufficient documentation errors, including incomplete progress notes, records that do not meet signature requirements, missing orders when required, and missing required elements. Many of these problems can be identified and corrected appropriately before submission, for example by locating a missing order that exists elsewhere in the record, adding a signature log, or obtaining records from a referring practitioner.

Contractor guidance has also noted that many denials are later overturned on appeal because providers submit documentation at the appeal level that was omitted from the original response. Catching those omissions before submission saves time, money, and appeal effort.

Ground Rules for Pre-Submission Review

Before using the checklist, establish clear rules:

• Never alter, backdate, or create documentation to fill gaps. CMS's Program Integrity Manual requires amendments, corrections, and delayed entries to clearly identify the date and author and to be clearly and permanently marked. Potentially fraudulent entries may be referred to a Unified Program Integrity Contractor.

• Signature attestations may be used only within CMS's rules. They must be signed by the author, may not be used for unsigned orders when a signature is required, and may not be used to backdate documentation.

• The goal is completeness and accuracy, not persuasion. Include all relevant documentation, organized clearly.

• Document the review. Keep a record of who performed the review and what was found.

The 25-Point Pre-Submission Checklist

Section A: Request and Claim Matching (Points 1 to 5)

1. Correct contractor and request. Confirm which contractor issued the request, the request date, the reference number, and the due date, and verify the contractor is legitimate.

2. Correct beneficiary. Confirm that every page belongs to the correct beneficiary, using at least two identifiers such as name and date of birth or Medicare Beneficiary Identifier.

3. Correct dates of service. Confirm that records cover every date of service under review, and that records for unrelated dates are excluded or clearly separated.

4. Correct claim and service. Confirm that the claim number, service, and codes in the request match your records and the documentation being sent.

5. All requested documents identified. List every document the request asks for and confirm each is included or accounted for.

Section B: Orders, Eligibility, and Program Requirements (Points 6 to 10)

6. Orders present and valid. Confirm that required orders, referrals, or documentation of intent to order are present, dated, and signed when required.

7. Certifications and plans of care. For services that require them, such as therapy, home health, hospice, and SNF care, confirm certifications, recertifications, and plans of care are present, timely, signed, and dated.

8. Face-to-face encounters. For services that require them, confirm the encounter is documented, performed by an allowed practitioner, within the required timeframe, and related to the service.

9. Program-specific requirements. Confirm other requirements, such as an inpatient admission order, a hospice election statement, a DMEPOS standard written order and proof of delivery, or prior authorization, are met.

10. Coverage policy elements. Compare the documentation with the applicable National Coverage Determination, Local Coverage Determination, and billing and coding article, and confirm each required element is addressed.

Section C: Medical Necessity and Clinical Support (Points 11 to 16)

11. Reason for the service. Confirm the record clearly explains why the service was needed for this patient at this time.

12. Clinical findings. Confirm that relevant history, exam findings, test results, and symptoms supporting the service are documented.

13. Assessment and plan. Confirm the provider's assessment and plan are documented and connected to the service billed.

14. Service actually provided. Confirm the record shows the service was performed as billed, including details such as procedures performed, time, units, and skilled interventions.

15. Level of service supported. Confirm the documentation supports the code, level, units, and modifiers billed. For evaluation and management services, remember that medical necessity is the overarching criterion and that the volume of documentation should not drive the level billed.

16. Supporting records included. Confirm that records from referring practitioners, prior visits, or related services that support medical necessity are included. CMS's manual allows reviewers to consider documentation of the beneficiary's condition before and after the service, and CMS advises billing providers to obtain supporting records from other settings.

Section D: Authentication (Points 17 to 20)

17. Signatures present. Confirm every entry the reviewer will rely on is signed by its author with a handwritten or valid electronic signature.

18. Illegible signatures addressed. Confirm that a signature log or printed name accompanies any illegible signature or initials.

19. Missing signatures handled appropriately. For missing signatures on documentation other than orders, determine whether an attestation from the author is appropriate. Remember that attestations are not accepted for unsigned orders when a signature is required.

20. Dates and credentials. Confirm entries are dated where required and that the author's credentials are identifiable.

Section E: Record Integrity (Points 21 to 23)

21. Amendments and late entries properly identified. Confirm any amendment, correction, or late entry is clearly labeled with the date and author, and that it was made in accordance with your policies.

22. No cloned or contradictory content. Review for copied notes, carried-forward findings that are inaccurate, and contradictions within the record. If problems exist, do not alter the record, but note them for internal follow-up and consider whether other documentation supports the claim.

23. Complete and legible copies. Confirm all pages are present, legible, not cut off, and in the correct orientation, and that EHR printouts include signatures, dates, and addenda.

Section F: Packet Quality and Submission (Points 24 to 25)

24. Packet organized. Confirm the ADR letter or barcode cover sheet is first, a cover letter and index are included if helpful, records are in a logical order, pages are numbered, and each claim's records are separate.

25. Submission ready. Confirm the submission method, address, and format match the request instructions, that protected health information is handled securely, that a copy of the complete packet is saved, and that the submission is scheduled well before the due date.

How to Perform the Review

Who Should Perform It

• A reviewer who did not assemble the packet, to provide a fresh perspective.

• A clinical reviewer for medical necessity questions.

• A coding reviewer for code and level-of-service questions.

• An ADR coordinator to confirm packet and submission requirements.

For smaller organizations, one experienced reviewer may cover several areas, but using a second set of eyes for high-value claims is recommended.

When to Perform It

Schedule the review early enough to fix problems, for example by day 20 to 25 of a 45-day request, and by day 15 of a 30-day UPIC request.

How Long It Takes

A straightforward claim may take 15 to 30 minutes. Complex inpatient, home health, or hospice claims may take longer. Plan staffing accordingly for large requests.

Document the Review

Use a checklist form for each claim that records the reviewer, date, each point checked, issues found, and actions taken.

What to Do When You Find Gaps

Missing Document That Exists Elsewhere

Search the EHR, scanned documents, other departments, and archived records. Missing orders, signed plans of care, and test results are often found elsewhere in the organization.

Missing Third-Party Records

Contact the referring practitioner or facility immediately, explain the deadline, and follow up regularly. Document your efforts.

Illegible Signatures

Add a signature log or confirm that a printed name appears with the signature.

Missing Signatures on Non-Order Documents

Ask the author whether they can review the entry and provide a signature attestation that complies with CMS rules.

Unsigned Orders Where a Signature Is Required

An attestation will not be accepted. Look for other valid evidence that the order requirement was met, such as an electronically signed version in the EHR or another signed document that meets the requirement.

Documentation That Does Not Support the Claim

If the record genuinely does not support the claim, do not alter it. Submit the complete record as it exists. Evaluate whether the claim was billed in error and whether there are similar claims that may involve overpayments under the 60-day rule at 42 CFR 401.305.

Cloned or Contradictory Documentation

Submit the record as it exists, identify any patient-specific information that supports the service, and flag the issue for internal education and template improvement.

Service-Specific Add-Ons to the Checklist

The 25 points apply to most claims, but some services need additional checks.

Inpatient Hospital

• Signed inpatient admission order present.

• Documentation supporting the expectation of a stay or other reasons for inpatient care.

• Discharge summary included.

• Physician documentation supports the principal and secondary diagnoses coded.

Home Health

• Face-to-face encounter within the required timeframe and related to the primary reason for home health.

• Certifying practitioner's records support homebound status and skilled need.

• Plan of care signed and dated, covering the episode under review.

• Visit notes for each billed visit.

Hospice

• Certifications for each benefit period, with narratives.

• Signed election statement.

• Face-to-face encounter for the third and later benefit periods.

• Interdisciplinary group plan of care and updates.

• Documentation supporting continued eligibility.

Outpatient Therapy

• Evaluation and plan of care with certification.

• Recertifications at required intervals.

• Treatment notes for each date of service, including time and skilled interventions.

• Progress reports at required intervals.

DMEPOS

• Standard written order with required elements.

• Treating practitioner's medical records supporting medical necessity.

• Face-to-face encounter and prior authorization, when required.

• Proof of delivery matching the item and date.

Physician Services

• Note for the date of service signed by the rendering practitioner.

• Documentation supporting the E/M level or procedure billed.

• Orders and results for related diagnostic tests.

• Documentation supporting modifiers billed.

Building Pre-Submission Review Into Your Workflow

To make pre-submission review routine rather than an afterthought:

• Add a review step to your ADR workflow, with an internal deadline.

• Assign reviewers in advance for each service line.

• Use a standard form so reviews are consistent.

• Require sign-off before any packet is submitted.

• Store completed review forms with the ADR file.

• Train new reviewers using sample packets and common errors.

• Periodically audit the reviews themselves to confirm quality.

Measuring Success

Track metrics to show the value of pre-submission review:

• Percentage of packets reviewed before submission.

• Number and type of gaps found and resolved.

• ADR approval rates before and after implementing reviews.

• Number of denials later overturned on appeal because of documentation omitted from the original submission.

• Average time to complete a review.

Sharing these results with leadership helps secure staffing and support for the process.

Common Pre-Submission Mistakes

• Skipping the review because of time pressure.

• Reviewing only whether documents are present, not whether they support medical necessity.

• Missing records from other departments or facilities.

• Including records for the wrong patient or date of service.

• Using attestations for unsigned orders.

• Making improper changes to records.

• Sending incomplete EHR printouts without signatures or addenda.

• Failing to keep a copy of the submission.

Turning Review Results Into Improvement

Pre-submission reviews generate valuable data. Track:

• The most common gaps by service line, provider, and department.

• How often third-party records are missing.

• Signature issues by provider.

• Template-related problems, such as cloned content.

• Time required for each review.

Use the results to:

• Update EHR templates to prompt for missing elements.

• Provide targeted clinician education.

• Improve processes for obtaining referring practitioner records.

• Maintain a current signature log.

• Prioritize internal audits.

• Report trends to the compliance committee.

A Hypothetical Example

A physical therapy clinic receives an ADR for six claims. The coordinator assembles the records, and a second reviewer applies the 25-point checklist. The review finds:

• For two claims, the plan of care certification is missing from the packet. The reviewer locates the signed certifications in a scanned documents folder.

• For one claim, a treatment note has an illegible therapist signature. The reviewer adds the clinic's signature log.

• For one claim, the progress report required for the period is missing. The reviewer locates it in a different EHR tab.

• For one claim, the treatment notes for two visits are nearly identical. The reviewer submits them as they exist and flags the issue for education.

The clinic submits the corrected, complete packets on day 26. Five of the six claims are approved. Without the pre-submission review, at least three claims would likely have been denied for missing documentation.

Pre-Submission Review Form Template

Organizations can create a simple form with these fields:

• Claim number, beneficiary, date of service, service.

• Contractor, request date, due date.

• Reviewer name and date.

• Checklist points 1 to 25, each marked complete, not applicable, or issue found.

• Description of issues and actions taken.

• Final approval to submit, with signature and date.

Quick Reference: The 25 Points

1. Correct contractor and request.

2. Correct beneficiary.

3. Correct dates of service.

4. Correct claim and service.

5. All requested documents identified.

6. Orders present and valid.

7. Certifications and plans of care.

8. Face-to-face encounters.

9. Program-specific requirements.

10. Coverage policy elements.

11. Reason for the service.

12. Clinical findings.

13. Assessment and plan.

14. Service actually provided.

15. Level of service supported.

16. Supporting records included.

17. Signatures present.

18. Illegible signatures addressed.

19. Missing signatures handled appropriately.

20. Dates and credentials.

21. Amendments and late entries properly identified.

22. No cloned or contradictory content.

23. Complete and legible copies.

24. Packet organized.

25. Submission ready.

Frequently Asked Questions

Is a pre-submission review required by Medicare?

No. It is a best practice that helps providers submit complete and accurate documentation and avoid preventable denials.

Can we add notes to the record during the review?

Only if the addition is a legitimate amendment or late entry that follows Medicare rules and your policies, clearly identifying the date and author. Never alter or backdate records to support a claim.

Should we include records the reviewer did not specifically request?

Include records that support the claim, such as relevant prior notes or referring practitioner records, organized clearly. Avoid sending unrelated records.

Who should sign off on the final packet?

A designated reviewer or ADR coordinator should approve the packet before submission, and high-value or complex claims may warrant clinical or compliance review.

What if we find a claim that should not have been billed?

Submit the records as they exist, and evaluate the billing error and any overpayment obligations, including whether similar claims are affected.

How is pre-submission review different from an internal audit?

A pre-submission review checks a specific packet before it goes to an auditor. An internal audit reviews a sample of claims to measure compliance and identify trends. Both are valuable, and findings from each should inform the other.

Should we use the same checklist for every contractor?

The 25 points apply broadly, but always add any specific instructions from the requesting contractor, such as cover sheet requirements, submission formats, and documents listed in the request.

What if the deadline is too close to complete a full review?

Prioritize the highest-risk points, such as claim matching, orders, signatures, and medical necessity support, and contact the contractor early if good cause exists for additional time.

Conclusion

A pre-submission documentation review is one of the simplest and most effective ways to reduce Medicare audit denials. The 25-point checklist confirms that records match the request, required orders and certifications are present, medical necessity is supported, signatures are authenticated, record integrity is maintained, and the packet is complete and ready to submit. By performing reviews consistently, documenting results, handling gaps appropriately, and using findings to improve templates and training, providers can make sure that every valid claim has the documentation it needs to be paid.

How HealthBridge Can Help

HealthBridge is a healthcare management consulting firm that helps providers design pre-submission review processes, build checklists and forms, perform independent reviews of ADR and audit responses, train staff, and use review findings to improve documentation. If you would like help reviewing records before they go to an auditor, please get in touch with us. We will be happy to help you with this topic.

References

• Centers for Medicare & Medicaid Services. Complying with Medical Record Documentation Requirements (MLN909160, December 2024). https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/CMS/certmedrecdoc_factsheet_icn909160.pdf

• Centers for Medicare & Medicaid Services. Medicare Program Integrity Manual, Chapter 3. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/pim83c03.pdf

• Centers for Medicare & Medicaid Services. Complying with Medicare Signature Requirements (MLN905364, July 2025). https://www.cms.gov/mln905364-complying-with-medicare-signature-requirements

• Centers for Medicare & Medicaid Services. Additional Documentation Request. https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-education/additional-documentation-request

• Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 12. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c12.pdf

• Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/bp102c15.pdf

• Centers for Medicare & Medicaid Services. Ensuring Proper Use of Electronic Health Record Features and Capabilities: A Decision Table (June 2016). https://www.cms.gov/files/document/ehrdecisiontable062816pdf

• Centers for Medicare & Medicaid Services. Fiscal Year 2025 Improper Payments Fact Sheet. https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2025-improper-payments-fact-sheet

• Centers for Medicare & Medicaid Services. Medicare Coverage Database. https://www.cms.gov/medicare-coverage-database/search.aspx

• U.S. Department of Health and Human Services. HIPAA Privacy Rule. https://www.hhs.gov/hipaa/for-professionals/privacy/index.html

• Electronic Code of Federal Regulations. 42 CFR 401.305, Requirements for Reporting and Returning of Overpayments. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-A/part-401/subpart-D/section-401.305

• Electronic Code of Federal Regulations. 42 CFR 405.930, Failure to Respond to Additional Documentation Requests. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-405/subpart-I/subject-group-ECFRba80b2c5e3f1227/section-405.930