Checklist: Surgical services - nail cutting/paring and debridement
This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for surgical services: cataract extraction. It is not intended to replace the published guidelines. Health care providers retain responsibility to submit complete and accurate documentation.
| Check | Documentation description |
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| Documentation is for the correct beneficiary. |
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| Documentation is for the correct date of service. |
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| Documentation contains a valid and legible signature. |
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| Documentation that includes evidence of a qualifying medical condition / disease(s) to support Medicare coverage requirements for routine foot care exclusion. |
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| Documentation demonstrates the medical necessity of each service considering the patient's usual activities including being actively seen by a primary care provider. |
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| Documentation includes evidence of a thorough physical examination to support the condition(s) being treated. |
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Documentation that includes evidence to support the reporting of one of the following applicable Q modifiers, if applicable: Q7 – 1 Class A finding Q8 – 2 Class B findings Q9 – 1 Class B and 2 Class C findings |
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Documentation for nail debridement should include: Clinical evidence of mycosis Clinical evidence of ambulation limitations due to discomfort Clinical evidence of secondary soft tissue infection Previous unsatisfactory conservative treatment |
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| Documentation supporting an order or request by the patient / patient's family for foot-care services provided in a nursing facility, if applicable. |
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Documentation that includes a procedure note with the following information, if applicable: Thorough / detailed description of the procedure being performed (beyond simple statements) and instruments used during the procedure Location of each lesion treated Identification (by number or name) and description of all nails treated Type of anesthesia utilized |
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| 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.