Checklist: Surgical services
CPT 37227 - vascular stenting lower extremities and 37229 - endovascular revascularization documentation
This checklist is intended to provide Healthcare providers with a reference for use when responding to medical documentation requests for surgery-revascularization procedures of lower extremity. It is not intended to replace the published guidelines. Healthcare providers retain responsibility to submit complete and accurate documentation.
| Check | Documentation description |
|---|---|
| Documentation is for the correct beneficiary and date of service. | |
| Documentation is for the complete, legible, signed and dated by the physician or clinician. | |
| The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT / HCPCS code must describe the service performed. | |
| Documentation includes evidence of a thorough physical examination to support the condition(s) being treated. | |
|
This documentation should also include, but is not limited, to the following (as applicable to the patient’s episode of care):
|
|
|
Documentation that includes a procedure note with the following information, if applicable:
|
|
| If applicable and required, submitted documentation should include a beneficiary waiver of liability. |
Disclaimer
This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.