“Can you describe what is a “sufficiently detailed exam” to confirm the diagnosis of peripheral arterial disease? I was audited and the debridement of calluses were denied even documentation of every single class finding were listed. Are we supposed to do ankle brachial indexes, Buerger’s test, etc.? Why have class findings if they do not qualify as “sufficiently detailed?”
I read over the above scenario and thought about responding and opining for a while before making a statement. Approximately two months ago, I opined to a scenario related to “minimum documentation” and “at risk” routine foot care. I believe that this is related to the issue at hand in today’s question.
I have a problem with the phrase “minimum documentation.” I believe the correct phrase should be “appropriate documentation.” With respect to the above post, the issue is a “sufficiently detailed exam.”
So, a patient qualifies for “At Risk” routine foot care and is returning regularly (i.e.. every 61 days) for follow up “At Risk” routine foot care encounters. Medicare Administrative Contractors do 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. In this instance, the paring of corns and calluses using CPT 11055, CPT 11056, or CPT 11057. 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 a medically appropriate examination and medical decision making. For example, if the patient has peripheral vascular disease (PVD) as the patient apparently has in this scenario, 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. It is inappropriate to just document the Q modifier in question in the medical record. As part of the lower extremity physical examination that was performed and should be performed on every “At Risk” routine foot care encounter, since the patient has PVD, not only does the examination need to support the physical findings that correctly support the use of a Q modifier, but a complete lower extremity vascular examination should be performed to identify ALL physical findings that demonstrate that the patient has PVD. An ankle brachial index (ABI) does not need to be performed, but specifically for a covered systemic disease of PVD, the lower extremity vascular examination needs to be complete, above and beyond the identification of class findings.
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. This is certainly part of the history component.
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)
The DPM’s podiatric diagnoses (ICD- 10-CM codes)
Of course, the above two issues need to be documented within the medical record as part of the history and the examination.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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