| 77599-9 | Additional documentation | required |
| 77598-1 | Externally defined CDEs Doc | required |
| 47420-5 | Functional status note | required |
| 77597-3 | Orders placed Doc | required |
| 18776-5 | Plan of care note | required |
| 48765-2 | Allergies &or adverse reactions Doc | required |
| 51847-2 | Eval+Plan note | required |
| 51848-0 | Eval note | required |
| 10210-3 | Phys find General status | required |
| 61146-7 | Goals | required |
| 75310-3 | Health concern Doc | required |
| 11383-7 | Patient problem outcome | required |
| 18841-7 | Hospital consultations Doc | required |
| 8648-8 | Hospital course note | required |
| 11369-6 | Hx of Immunization note | required |
| 69730-0 | Instructions | required |
| 62387-6 | Interventions | required |
| 46264-8 | Hx medical device use | required |
| 10160-0 | Hx of Medication use | required |
| 10190-7 | Mental status | required |
| 61144-2 | Diet+nutrition | required |
| 61149-1 | Objective | required |
| 48768-6 | Payment sources Doc | required |
| 29545-1 | Physical findings note | required |
| 11450-4 | Problem list Reported | required |
| 47519-4 | Procedures Hx Doc | required |
| 30954-2 | Relevant dx tests/lab data note | required |
| 61150-9 | Subjective | required |
| 11537-8 | Surgical drains | required |
| 8716-3 | Vital signs note | required |
| 81245-3 | Interval Doc CDP1 R1.0+R1.1 | |