“I have a problem with the phrase ‘minimum documentation.’ I believe the correct phrase should be ‘appropriate documentation’.”
So, a patient qualifies for “At Risk,” Routine Foot Care and is returning regularly (ie. every 61 days) for follow up “At Risk,” Routine Foot Care encounters. Medicare Administrative Contractors such as First Coast Service Options does not find it appropriate to run one date of service into the next, in effect “cloning” the information from one “At Risk,” Routine Foot Care encounter to the next. Medicare Administrative Contractors expect all encounters to stand upon their own documentation as if this was the only time that the patient was treated, with no effect on what happens afterwards, and it has no bearing upon what happened previously. A specific date of service needs to be a self-contained note. Let’s face it. When a physician is audited by CMS/Medicare, they ask for specific dates of service.
Even though an E/M service is not being billed, CPT/procedure codes are being billed. Since every CPT code has an E/M component to it, the justification for billing the CPT/Procedure code(s) must be documented and verified. Therefore, it is important when a follow up “At Risk,” Routine Foot Care encounter is provided, the documentation needs to contain a medically appropriate history and examination and medical decision making. For example, if the patient has vascular issues and qualifies for a Q modifier, the documentation for the date of service needs to show the documentation to support the Q modifier that is being used. If the patient has neurological issues, the neurological issues need to be documented as described within the LCD and the associated article for Billing and Coding. If the patient is on anticoagulation therapy, the documentation needs to be supported by the information as stated within the LCD and the associated article, as well.
In addition to the medically appropriate history and examination, as well as medical decision making, it is certainly important to document the patient’s Subjective findings, or what brings the patient to the office on this date of service. If there are any changes in the patient’s health, medications, etc., this should really be documented.
As part of the examination, it is imperative to include the Systemic disease and associated complication(s) resulting from the disease (These are the Class Findings that lead you to select the appropriate Q modifier).
With respect to the Assessment, the verbiage for the ICD-10-CM codes that qualify the patient for “At Risk,” Routine Foot Care must be documented:
The systemic disease (ICD- 10-CM code)
DPM’s Podiatric Diagnoses (ICD- 10-CM codes)
Of course, the above 2 issues need to be documented within the medical record as part of the history and the examination.
With respect to the Plan, the description of the services rendered must be based upon the CPT code(s) billed. “Nails cut” is insufficient.
For example:
11055 Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion
11056 Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); 2 to 4 lesions
11057 Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); more than 4 lesions
11719 Trimming of nondystrophic nails, any number
G0127 Trimming of dystrophic nails, any number
11720 Debridement of nail(s) by any method(s); 1 to 5
11721 Debridement of nail(s) by any method(s); 6 or more
This is my opinion.
Michael G. Warshaw, DPM, CPC
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