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Medical School Healthcare Billing Compliance
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  • Team
    • Meet the Team
    • Jay McVean, Executive Director
    • Angelia Cain, CCA, Surgery
    • Barbara Montemayor, CCA, Pedi-Surgery & Anesthesia
    • Betty Babin, BCPM, Internal Medicine
    • Brandi Leonard, CCA, Family Medicine
    • Caroline Wolbrecht, CEPM
    • Chioma Ekpe-Hunter, CCA, Internal Medicine
    • Freda Washington, RCM, DII
    • Jatoi Johnson, SCS
    • Kourtnie Washington, AA
    • Maria Vazquez, CCA – Neurology, Neurosurgery, and PM&R
    • Padmavathi Annaldasula, SCCA, Emergency Medicine
    • Ronna Foster, SCCA – ORL, EP, and AHF
    • Stephanie Salazar, CCA, Orthopedics
    • Te’Ann Parker, CCA, Pediatrics
  • Coding Compliance
    • Coding Compliance Overview
    • 2025 Coding Compliance Changes
    • Compliance Resource Tools
    • Common Compliance Links
    • FREE CEU/CME Opportunities
    • Inherent Complexity Code – G2211
    • Psychotherapy is on Medicare’s Radar
    • Global Surgery Package – Our Future?
    • Closed Fracture Care with Manipulation
    • Injection Series: Part One – Hyaluronic Acid (HA)
    • Injection Series: Part Two – Facet Joints (Paravertebral)
    • Injection Series: Part Three – Trigger Points
    • Injection Series: Part IV – (ESI) Epidural Steroidal Injection
    • Locum Tenens – Has a New Name
    • Why is “Pajama Time” still a thing?
    • Implantable Infusion Pumps for Chronic Pain
    • Owe CMS a refund?
  • Teaching Physician Rules – The Basics
    • Teaching Physician Attestations – E/M
    • Teaching Physician Attestations – Primary Care Exception
    • Teaching Physician Attestations – Procedures
  • E/M Overview
    • Shared/Split Visits: 2024 Rules
    • Shared Visits – Still Puzzled?
    • “Incident-to” Billing Basics
    • E/M: Medical Decision Making 101
    • E/M: Documenting Time in 2023
    • E/M + Procedure = Modifier -25
    • E-Visits – What you need to know!
    • Newborn Care Services 101
    • Critical Care 101
    • 2023: Home or Residence Services
    • Medicare Wellness Exams
    • Pre-Procedural Examinations – Z01.818
    • 2023 Inpatient E/M Changes
    • CMS FY 2023 Final Rule Changes – Prolonged Services
    • Initial Inpatient or Observation Care Services – CPT
    • Initial Inpatient or Observation Care Services – Medicare
    • Patient is not Inpatient or Observation Status
    • SDoH – Social Determinants of Health
    • Advanced Primary Care Management (APCM)
    • MTM – Medication Therapy Management
    • Medical Record Documentation Checklists
    • Care Management Services Overview
  • Hierarchical Condition Category Coding
    • Hierarchical Condition Category Coding Overview
    • The Problem List Problem
    • HCC Documentation Tip Sheets
    • Documentation Quick Tips!
  • E/M Overview
    • “Incident-to” Billing Basics
    • Advanced Primary Care Management (APCM)
    • Care Management Services Overview
      • Series Part I: Chronic Care Management Services
      • Series Part II: Complex Chronic Care Management Services
      • Series Part III: Principal Care Management Basics
    • E-Visits – What you need to know!
    • Inherent Complexity Code – G2211
    • Newborn Care Services 101
    • PHE is ending – What does that mean?
      • Let’s talk about Telehealth
    • Pre-Procedural Examinations – Z01.818
    • Shared/Split Visits: 2024 Rules
    • 2023 Inpatient E/M Changes
      • Critical Care 101
      • SDoH – Social Determinants of Health
      • CMS FY 2023 Final Rule Changes – Prolonged Services
      • Initial Inpatient or Observation Care Services – CPT
      • Initial Inpatient or Observation Care Services – Medicare
      • 2023: Home or Residence Services
    • Medical Record Documentation Checklists

Medical Record Documentation Checklists

Documentation

Novitas Documentation Checklists

General Documentation Requirements
  • Medical Documentation and Checklists
Hospital Outpatient Department (OPD) Services
  • Medical Record Checklist
Lab Services
  • Laboratory Services Documentation Checklists
Medicare Audit Contractors
  • Targeted Probe and Educate (TPE) Documentation Checklists 
Mental Health
  • Psychotherapy Services Documentation Checklist

Preventive Services

  • Initial Preventive Physical Examination (IPPE) Documentation Checklist
  • Annual Wellness Visit (AWV) Documentation Checklist
  • Texas Health Steps Child Clinical Record Forms
Procedures
  • Anesthesia Services Documentation Checklist
  • Cataract Extraction Checklist:
  • Drugs, Biologicals and Injection Services Documentation Checklist
  • Epidural Steroid Injection Services Documentation Checklist
  • Moh’s Micrographic Surgery
  • Nail Cutting Pairing and Debridement Documentation Checklist
  • Therapy Services (PT, OT, ST) Checklist
Rehab
  • Cardiac Rehab Checklist
  • Pulmonary Rehab Checklist

 

Medical School Healthcare Billing Compliance
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