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Medical documentation checklists

Modified: 2/24/2025
This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for Transitional Care Management. Health care providers retain responsibility to submit complete and accurate documentation.
Modified: 10/16/2024
This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for paravertebral facet joint injection services
Modified: 10/16/2024
This checklist is intended as reference to use when responding to medical documentation requests for IRF services.
Modified: 10/16/2024
This checklist is an aid to assist providers when responding to medical record documentation requests pertaining to Community Mental Health Centers (CMHC) or Partial Hospitalization Program (PHP).
Modified: 10/16/2024
This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for surgery-revascularization procedures of lower extremity.
Modified: 9/25/2024
This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for AWV. Health care providers retain responsibility to submit complete and accurate documentation.
Modified: 7/26/2024
This checklist is being provided as a tool to assist providers when responding to medical record documentation requests for cardiac rehabilitation services.
Modified: 7/26/2024
This checklist is being provided as a tool to assist providers when responding to medical record documentation requests for pulmonary rehabilitation services.
Modified: 5/31/2024
This checklist is intended to provide health care providers with a reference for use when responding to additional documentation requests for E/M services (on or after January 1, 2023, for office/outpatient services and on or after January 1, 2023, for all other services). Health care providers retain responsibility to submit complete and accurate documentation. Additional tools and interactive score sheets are available to assist you on our website under our Evaluation and Management section.
Modified: 5/7/2024
This checklist is being provided as a tool to assist providers when responding to medical record documentation requests for nursing home services.
Modified: 5/6/2024
This checklist is an aid to assist providers with documentation pertaining to psychotherapy services.
Modified: 4/30/2024
This checklist is intended to provide health care providers with a reference for use when responding to additional documentation requests for skin substitutes. Healthcare providers retain the responsibility to submit complete and accurate documentation.
Modified: 4/10/2024
This checklist is intended to provide health care providers with a reference for use when responding to additional documentation requests for emergency ambulance transports.
Modified: 4/10/2024
This checklist is an aid to assist providers with responding to medical record documentation requests.
Modified: 4/3/2024
This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for surgical services: cataract extraction.
Modified: 4/3/2024
This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for ESRD services.
Modified: 4/3/2024
This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for nail cutting/paring and debridement services.
Modified: 3/19/2024
This checklist is being provided as a tool to assist providers when responding to medical record documentation requests for endovascular cardiac valve replacement and supplement procedures (DRG 266 and 267).
Modified: 3/13/2024
This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests pertaining to diagnostic radiology.
Modified: 3/13/2024
This checklist is intended to provide health care providers with a reference for use when responding to additional documentation requests for wound debridement.
Modified: 3/13/2024
This checklist is being provided as a tool to assist providers when responding to medical record documentation requests for chemotherapy, drugs, biologicals, and injection services.
Modified: 3/6/2024
This checklist is intended to provide health care providers with a reference for use when responding to additional documentation requests for wound care.
Modified: 1/1/2024
Medicare home health referrals must contain information in the medical record from the certifying physician and/or acute/post-acute care facility justifying the referral. Use this checklist to gain an understanding of the criteria necessary for home health referrals.
Modified: 5/18/2023
This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests pertaining to clinical lab drug testing. Health care providers retain responsibility to submit complete and accurate documentation.
Modified: 5/18/2023
This checklist is intended to provide health care providers with a reference for use when responding to additional documentation requests for emergency ambulance transports.
Modified: 5/18/2023
This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for outpatient hospital services.
Modified: 5/18/2023
This checklist is intended to provide healthcare providers with a reference for use when responding to medical documentation requests for therapeutic radiation services.
Modified: 5/12/2023
This checklist is an aid to assist providers with responding to medical record documentation requests.
Modified: 5/5/2023
This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for hyperbaric oxygen therapy (HBO) services.
Modified: 5/3/2023
This checklist is being provided as a tool to assist providers when responding to medical record documentation requests for critical care services.
Modified: 4/28/2023
This checklist is being provided as a tool to assist providers when responding to medical record documentation requests for other musculoskeletal system and connective tissue OR procedures (DRG 515, 516 and 517).
Modified: 4/28/2023
This checklist is being provided as a tool to assist providers when responding to medical record documentation requests for cardiac defibrillator implant w/o cardiac cath (DRG 226 and 227) services.
Modified: 4/28/2023
This checklist is being provided as a tool to assist providers when responding to medical record documentation requests for major hip and knee joint replacement or reattachment of lower extremity (DRG 469 and 470) services.
Modified: 4/28/2023
This checklist is being provided as a tool to assist providers when responding to medical record documentation requests for percutaneous intracardiac procedures (DRG 273 and 274).
Modified: 4/27/2023
This checklist is being provided as a tool to assist providers when responding to medical record documentation requests for aftercare, musculoskeletal system and connective tissue (DRG 559, 560 and 561) services.
Modified: 4/27/2023
This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for Chronic Care Management (CCM) services.
Modified: 4/27/2023
This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for Drugs and Biologicals.
Modified: 4/27/2023
This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for therapy and rehabilitation services.
Modified: 12/7/2022
This checklist is an aid to assist providers with responding to skilled nursing facility documentation requests.
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.