Documentation for toenail trimming

[Keitha L Scheib]

I'm posting and auditing for a podiatrist. I'm new to this specialty and need some help. My manager believes every minor procedure needs a "mini" op note, including toenail trimming to include number trimmed, what was used to trim and outcome. Does anyone know of guidelines to back this up? Our podiatrist is a "show me the proof" type.

 

[tdvrana]

"mini" op note

Off the top of my head I don't have exact documentation resources for you but there is ample of it. I'd start with searching past AAPC magazine articles and of course googling. AAPC has had some good articles regarding the need for documentation of a procedure done to substantiate or justify qualifying for a procedure being done in addition to an e/m. That goes for any provider, any procedure so I don't know where your podiatrist is getting the idea that he/she doesn't need to document something being done. And since so much of routine foot care and podiatry is denied, they better make darn sure they have good documentation.

 

[mray906]

It 100% should be documented, it doesn't have to be set up as a mini-op report but it should have all the information contain in the note to make sure that what they are billing for is documented. It should always have number of nails trimmed, what method was used, etc, also I always try to make sure that my docs include in their dictation the Q modifier information (if applicable) just incase we ever have to go back to research if it was omitted from a claim.


Hope this helps