Targeted Probe and Educate documentation checklists

These checklists are intended to provide healthcare providers with a reference for use when responding to additional documentation requests for the selected TPE topic. It is not intended to replace any guidelines from CMS. Healthcare providers retain responsibility to submit complete and accurate documentation upon request to Medicare.

Topic	Checklist
Psychiatric services: Psychotherapy	Documentation checklist
Laboratory services	Documentation checklist
Rehabilitation services: Outpatient physical and occupational therapy	Documentation checklist
Drug and biologicals: Drug injections	Documentation checklist
Cardiac rehabilitation services	Documentation checklist
Paravertebral facet joint injections	Documentation checklist
Surgical services: Nail debridement/Paring or cutting of hyperkeratotic lesions	Documentation checklist
Surgical services: Cataract extraction	Documentation checklist
Pulmonary rehabilitation services	Documentation checklist
End stage renal disease (ESRD) services	Documentation checklist
Initial preventive physical examination (IPPE) and annual wellness visit (AWV)	Documentation checklist (IPPE) Documentation checklist (AWV)
Surgical services: Mohs micrographic surgery (MMS)	Documentation checklist
Ambulance services: Emergent ambulance transport	Documentation checklist
Anesthesia services: Anesthesia for diagnostic or therapeutic injections	Documentation checklist
Trigger point injections	Documentation checklist
Epidural steroid injections	Documentation checklist
Benign skin lesion removal	Documentation checklist
Acupuncture	Documentation checklist
Evaluation and Management Services	Documentation checklist

Was this page helpful?

Last modified: 06/08/2023

Person(s) with Medicare