I have been running into a provider who continues to bill for services: 11056 but there is no procedure documentation to support it or am interpreting it wrong, help!
Should I be letting the provider know the lack of documentation or is this enough?
Is there any specific documentation requirements that someone can direct me too so I can send the provider
SUBJECTIVE: This patient returns for follow-up of elongated, thick, dystrophic and mycotic nails 1-5, bilaterally. She is here for nail care. She is also here for follow up of callous plantar 1st mpj of the left foot.
OBJECTIVE: Patient has elongated, thick, dystrophic, mycotic and gryphotic nails 1-5 bilaterally. Some are incurvated, cracked and breaking off. Clavus plantar 1st mpj of the left foot. Onychocryptosis medial right hallux. No paronychia or infection
ASSESSMENT:
Elongated, thick, dystrophic and mycotic nails 1-5, bilaterally.
Keratoma plantar 1st MPJ of the left foot.
Onychocryptosis medial right hallux.
PLAN:
Debrided all the hyperkeratotic lesions down and accommodated them.
Pt given instruction for appropriate conservative care of padding, exfoliation and hydration with exfoliative cream.
Should I be letting the provider know the lack of documentation or is this enough?
Is there any specific documentation requirements that someone can direct me too so I can send the provider
SUBJECTIVE: This patient returns for follow-up of elongated, thick, dystrophic and mycotic nails 1-5, bilaterally. She is here for nail care. She is also here for follow up of callous plantar 1st mpj of the left foot.
OBJECTIVE: Patient has elongated, thick, dystrophic, mycotic and gryphotic nails 1-5 bilaterally. Some are incurvated, cracked and breaking off. Clavus plantar 1st mpj of the left foot. Onychocryptosis medial right hallux. No paronychia or infection
ASSESSMENT:
Elongated, thick, dystrophic and mycotic nails 1-5, bilaterally.
Keratoma plantar 1st MPJ of the left foot.
Onychocryptosis medial right hallux.
PLAN:
Debrided all the hyperkeratotic lesions down and accommodated them.
Pt given instruction for appropriate conservative care of padding, exfoliation and hydration with exfoliative cream.
Pt given instructions for appropriate padding and accommodation to the areas of bony prominence.
Discussed with the patient appropriate shoe gear and soft insoles.
Pt RTC 3 months
Discussed with the patient appropriate shoe gear and soft insoles.
Pt RTC 3 months
