CMS-1500 Superbill Source Document: The Patient's Complete Medical Record (Notes, Labs, Imaging, Treatment Plans)

The CMS-1500 (02/12) claim form is completed using data from the patient's medical record — the legal, chronological documentation of all clinical encounters.

Source Record Components

• Initial Evaluation: H&P, problem list, diagnoses (ICD-10-CM).
• Progress Notes: SOAP format; date, provider, findings, assessment, plan.
• Orders & Results: Labs, imaging, pathology, ECGs, etc.
• Procedures: Operative notes, anesthesia records, CPT/HCPCS codes.
• Treatment Plans: Medications, referrals, DME, therapy orders.
• Demographics & Insurance: Face sheet, copies of cards, authorizations.

Accuracy Imperative

Claims must reflect exactly what is documented. Upcoding, unbundling, or billing for undocumented services constitutes fraud (False Claims Act). Regular audits and coder-clinician collaboration ensure compliance.