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Laterality (left or right) is explicitly documented in the record The most specific code supported by documentation is being used The code has been updated if a definitive diagnosis was confirmed after the initial visit Traumatic and non-traumatic codes aren't mixed on the same claim Documentation supports medical necessity for every service billed External cause codes (V00-Y99, Y92) are included where applicable, especially on initial encounters CPT codes align with the ICD-10 diagnosis code Seven checkpoints

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The checklist can also be administered by various direct caregivers including but not limited to parents, healthcare workers, and educators

Sometimes, patients must undergo tests and assessments to determine the appropriate medication and dosage

doi: 10.1158/1541-7786.MCR-11-0605