CMS-1500 Initiative Medical Narrative Requirements

The Initial Narrative Report should include all the requirements below.

• Rendering Provider's Name

Work Status

• Has the patient missed work because of the injury/illness? If yes, provide the date the patient first missed work?
• Is the patient working? If yes, provide the date(s) the patient:
  • Resumed limited work of any kind
  • Resumed full work
• If the patient is not working, 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)

Temporary Impairment

• What is the percentage (0-100%) of temporary impairment?
• Describe findings and explain how impairment percentage was determined

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 of the Injury/Illness

• Where and how the injury/illness occurred
• Details regarding the nature of injury/illness. Identify specific body part(s) affected
• Symptoms and relevant review of symptoms (e.g., onset, duration, associated symptoms, alleviating and exacerbating factors)
• Function:
  • On the date of injury/illness what was the patient's job title and usual work activities
  • Specific functional work activities and/or Activities of Daily Living (ADL) that patient cannot perform as a result of injury/illness
• Previous treatment for the injury/illness including hospitalization and/or surgery and reported patient response (effectiveness of treatment)
• Relevant medical history, including:
  • Any prior treatment for a similar work-related injury/illness and/or
  • Any prior injury or treatment to the affected body part(s)
• Medications
• Clear documentation of current medications including dose, frequency and patient response, and
• History of previous medications and patient response

Objective Findings/Clinical Evaluation

• Physical examination (describe all relevant findings according to History Taking and Physical Examination sections found in each Medical Treatment Guideline and per standard clinical practice for non-MTG injuries)
• Diagnostic procedure(s)/test(s) performed prior to the visit
• Diagnostic procedure(s)/test(s) performed during the visit
• Treatment rendered at time of exam, if any (e.g., casting, suture/suture removal, injections)

Diagnosis(es)/Assessment

• Clear identification of diagnosis(es), including differential diagnosis (i.e., not a listing of ICD or CPT billing codes)
• Identify patients with delayed recovery (pain and functional limitations that persist beyond the anticipated time of healing and recovery) early and evaluate per Non-Acute Pain Medical Treatment Guidelines (NAP MTG)

Plan of Care

• Proposed treatment and treatment goals (include type of treatment, frequency and anticipated duration of treatment)
• 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
• Prognosis for recovery
• Follow-up appointment(s)