Wiki Diabetic Footcare Documentation

[twalls]

Hello Folks! When the pt comes in for diabetic footcare is it required for the Dr. to document in their note who the PCP is and the date last seen?? I have a couple providers who just will not document this information. The front desk calls the PCP's office and obtains this information so we can bill the 11720,11055, ect. But if it is audited, shouldn't it truly be in the provider's documentation? Having a tough time finding an answer and the LCD doesn't necessarily specify either.

Thank you! Happy Friday!
Tammy

 

[podcoder70]

Great question!! Medicare requires that the patient is under the care and supervision of a medical provider that treats the diabetes to qualify for routine foot care such as the treatment of nails and calluses. For that reason, the name of the PCP and the APPROXIMATE date last seen needs to be documented in the note.
The most efficient way to obtain this information is when the patient is taken to the exam room, the podiatry assistant should be collecting this information from the patient and either entering it into the encounter or giving it to the podiatrist to enter into the encounter.

Most other payers do not require this information, but it's just best to get into the habit. Many Medicare jurisdictions require this data on the claim as well for those with diabetes. Rule of thumb, if the LCD states the information is required on the claim, then it should be documented in the encounter as well.

 

[TThivierge]

Hi
Umm that can be a problem. Maybe your EHR program can add screen just for listing consult info from other providers. If this is the case the office secretaries could add that referring doc's name in. Or keep encouraging the treating physician to add in his documentation the referring doctor's name sent patient to him for podiatry issues. We add this on our claim format too most payers want this data.
Well I hope I helped you. Have a great day!
Lady T

 

[jayaprakash.jayasheelan@clinicanywhere.com]

Great question!! Medicare requires that the patient is under the care and supervision of a medical provider that treats the diabetes to qualify for routine foot care such as the treatment of nails and calluses. For that reason, the name of the PCP and the APPROXIMATE date last seen needs to be documented in the note.
The most efficient way to obtain this information is when the patient is taken to the exam room, the podiatry assistant should be collecting this information from the patient and either entering it into the encounter or giving it to the podiatrist to enter into the encounter.

Most other payers do not require this information, but it's just best to get into the habit. Many Medicare jurisdictions require this data on the claim as well for those with diabetes. Rule of thumb, if the LCD states the information is required on the claim, then it should be documented in the encounter as well.

Thank you so much for the clarification. I have one doubt related to this question. If our provider is treating a patient from past 1 year which last seen date do I need to update. We obtained the last seen date from the patient's PCP for this first time but its been a year the patient is visiting our provider for the footcare. The last seen date should be within 6 months so should the patient go back to his/her PCP every 6 months to obtain a last seen date or can we use previous visit date as last seen date.
Thank you!

 

[podcoder70]

Thank you so much for the clarification. I have one doubt related to this question. If our provider is treating a patient from past 1 year which last seen date do I need to update. We obtained the last seen date from the patient's PCP for this first time but its been a year the patient is visiting our provider for the footcare. The last seen date should be within 6 months so should the patient go back to his/her PCP every 6 months to obtain a last seen date or can we use previous visit date as last seen date.
Thank you!

I hope I am understanding your question correctly. When performing callus and/or nail treatment on a diabetic or other patients with and asterisked diagnosis as per your local LCD, that patient must have the name of the doctor treating the diabetes or other condition and the approximate date that the patient was seen by that doctor (usually a primary care, sometimes an endocrinologist). That date does not need to be changed every 9 weeks that the DPM when the patient is seen for nails/callus treatment as long as the date is within 6 months of treatment. For example, if you see the patient on 10/19 then the date last seen should not be older than 4/19.