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First Coast Service Options Inc.
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Medical documentation

The “Golden Rule” of medical documentation is, “If you didn’t document it, then it hasn’t been done.” Medical record documentation is required to record pertinent facts, findings, and observations about an individual’s health history including past and present illnesses, examinations, tests, treatments, and outcomes.
• What is medical documentation?
• Tips for documenting medical records
• Medical documentation FAQs
• Additional development request (ADR)/medical review timeliness calculator
Medical documentation news
Check here for the latest news pertaining to medical documentation.
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Medical documentation checklists
• General checklist -- click here pdf file
In addition to the general documentation tips above, the following are links to minimum documentation recommendations based on specified services.
• Evaluation and management (E/M) services -- click here pdf file
• Inpatient admissions -- click here pdf file
• Ambulance transports -- click here pdf file
• Chiropractic services -- click here pdf file
• Power mobility device face-to-face examination checklist -- view special edition MLN Matters article SE1112 external link to pdf.
• Skilled nursing facility (SNF) checklist -- click here pdf file
• Outpatient therapy and rehabilitation services – click here pdf file
Signature requirements
• 20-day timeframe for additional documentation requests
• Authentication requests for missing or illegible signatures
• Guidelines for authentication of Medicare services
• Physician requirements for medical documentation flash file
• Signature requirements FAQ
Medical policy news
The medical policy news page keeps you up to date with the latest news related to local coverage determinations (LCDs).
Online learning -- FCSO Medicare training website
• FCSO University external link
• FCSO’s online Medicare training catalog -- Part A
• FCSO’s online Medicare training catalog -- Part B
Education resources
The following are resources also designed to assist providers:
• Comprehensive error rate testing (CERT) -- This link will take you to FCSO’s CERT page where you will find important information concerning this initiative.
• CERT program reference guide -- This guide shows the end-to-end CERT process, to include how to respond to medical record documentation requests.
• New 'Comprehensive Error Rate Testing Signature Requirements' fact sheet -- This fact sheet describes common denials related to signature requirements and includes information on the documentation needed to support a claim submitted to Medicare for medical services.
• Evaluation and management (E/M) -- This link will take you to FCSO’s E/M page where you will find links for the interactive E/M worksheet.
• Specialty pages -- we have set up specialty pages for both Part A and Part B that give you informative information. Please click on the link pertinent to your line of business.
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First Coast Service Options (FCSO) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.