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Medical documentation checklists
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Aftercare, musculoskeletal system and connective tissue
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Annual wellness visit (AWV)
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Application of skin substitutes
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Cardiac defibrillator implant w/o cardiac cath
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Cardiac rehabilitation services
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Cataract extraction
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Chemotherapy, drugs, biologicals, and injections
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Chiropractic services documentation
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Chronic care management (CCM)
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Clinical laboratory
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CMHC / PHP
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Critical care service
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Diagnostic radiology
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Drugs and Biologicals
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Emergent ambulance services documentation
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Endovascular cardiac valve replacement and supplement procedures
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ESRD documentation
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Evaluation and management (E/M) services
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Home health referrals
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HBO therapy documentation
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Inpatient admission documentation
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Inpatient rehabilitation facility (IRF)
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Major hip and knee joint replacement or reattachment of lower extremity
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MOHs
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Musculoskeletal system and connective tissue or procedures
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Nursing home
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Outpatient hospital services documentation
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Outpatient therapy and rehabilitation services
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Paravertebral facet joint injection services documentation
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Percutaneous intracardiac procedures
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Psychotherapy services
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Pulmonary rehabilitation services
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Skilled nursing facility documentation
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Skin lesion removal
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Surgical services: Nail cutting/paring and debridement
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Surgical services: Vascular stenting CPT 37227
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Therapeutic radiation-radiology services documentation
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Transitional care management
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Wound debridement
Medical documentation checklists
Use the links on the left to access a checklist for the selected topic. These checklists are intended to provide healthcare providers with a reference for use when responding to additional documentation requests. They are not intended to replace any guidelines from CMS. Healthcare providers retain responsibility to submit complete and accurate documentation upon request to Medicare.