Medical documentation

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Home ► Part B ► Medical documentation

Medical documentation

News

View the latest medical documentation news

Target probe and educate (TPE) external link

– View this video, presented by CMS, to learn more about the TPE process and help you identify and correct common errors on Medicare claims.

ADR (Additional documentation requests)

Find information and resources that will help you properly respond to additional documentation requests within required timeframes.

ADR by fax FAQ

ADR fax coversheet: Part A pdf file

ADR fax coversheet: Part B pdf file

ADR: Response time FAQ

ADR timeliness calculator

Timely response to ADRs

Learn how to update your correspondence address to ensure you receive your ADRs

ADR response using secure messaging in SPOT. Scroll down to the Submission guidelines: ADR form section for guidance on how to respond to your ADR request online.

Medical documentation checklists

Use these checklists to ensure you have met medical documentation requirements based on specific services.

General medical documentation checklist pdf file

E/M checklist pdf file

Ambulance transportation checklist pdf file

Chiropractic services checklist pdf file

Inpatient admissions checklist pdf file

IRF documentation checklist pdf file

Outpatient therapy and rehabilitation checklist pdf file

Skilled Nursing Facility checklist pdf file

Clinical labs checklist

Hyperbaric oxygen (HBO) therapy checklist pdf file

Psychotherapy services checklist pdf file

Signature requirements

Learn about signature requirements guidelines established by CMS as well as the importance of properly authenticating medical records.

Signature requirements: Guidelines for authentication

Signature requirements: Guidelines for Medical Review flash file

Signature requirements: ADR requests

Complying with Medicare Signature Requirements fact sheet external pdf file

esMD

Learn information about the electronic submission of medical documentation (esMD) program and the benefits of participation.

esMD program: Overview external link

esMD program: CMS News external link

esMD program: Provider FAQs external link

PWK

Learn how PWK, the paperwork segment of the X12N version 5010, allows providers to submit medical documentation with their initial claim.

How to submit medical documentation using PWK

New forms; required on and after April 1, 2018

• Medicare Part A fax/mail/esMD coversheet pdf file

• Medicare Part B fax/mail/esMD coversheet pdf file

PWK fax/mail/esMD coversheet: Requirements

Resources

Take advantage of these additional resources to gain a better understanding of medical documentation.

Medical documentation FAQs

Medical Documentation Requests (English) external link

Medical Documentation Requests (Spanish) external link

Medical Review

First Coast Service Options (First Coast) 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.