Medical CPT Code Documentation Checklist
Use this checklist to document completion of key elements required to support a CPT code claim. Ensure all relevant sections are completed before submission.
Date of Encounter
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Provider Name
*
First Name
Last Name
CPT Code
*
Patient Identifier (Initials or Chart # Only)
History Documented
*
Yes
No
Exam Documented
*
Yes
No
Medical Decision Making Documented
*
Yes
No
Procedure Performed Documented
*
Yes
No
Time Spent Documented (if required)
Yes
No
Attestation: All required documentation is complete and accurate.
*
I attest that the above information is complete and accurate.
Submit Checklist
Should be Empty: