11/21/2023    Michael G. Warshaw, DPM, CPC

Query: Sufficiently Detailed Exam

Can you describe what is a “sufficiently detailed
exam” to confirm the diagnosis of peripheral
arterial disease? I was audited and the
debridements of calluses were denied even
documentation of every single class finding were
listed. Are we supposed to do ankle brachial
indexes, Buerger’s test, etc.? Why have class
findings if they do not qualify as “sufficiently
detailed?”

PM News Subscriber

Response: I have a problem with the phrase
“minimum documentation.” I believe the correct
phrase should be “appropriate documentation.” With
respect to the above post, the issue is a
“sufficiently detailed exam.”

So, a patient qualifies for “at risk” routine foot
care and is returning regularly (i.e.. every 61
days) for follow up “at risk” routine foot care
encounters. Medicare Administrative Contractors do
not find it appropriate to run one date of service
into the next, in effect “cloning” the information
from one “at risk” routine foot care encounter to
the next. Medicare Administrative Contractors
expect all encounters to stand upon their own
documentation as if this was the only time that
the patient was treated, with no effect on what
happens afterwards, and it has no bearing upon
what happened previously. A specific date of
service needs to be a self-contained note. Let’s
face it… when a physician is audited by
CMS/Medicare, they ask for specific dates of
service.

Even though an E/M service is not being billed,
CPT/procedure codes are being billed. In this
instance, the paring of corns and calluses using
CPT 11055, CPT 11056, or CPT 11057. Since every
CPT code has an E/M component to it, the
justification for billing the CPT/Procedure
code(s) must be documented and verified.
Therefore, it is important when a follow up “at
risk” routine foot care encounter is provided, the
documentation needs to contain a medically
appropriate history and a medically appropriate
examination and medical decision making. For
example, if the patient has peripheral vascular
disease (PVD) as the patient apparently has in
this post, and qualifies for a Q modifier, the
documentation for the date of service needs to
show the documentation to support the Q modifier
that is being used. It is inappropriate to just
document the Q modifier in question in the medical
record. As part of the lower extremity physical
examination that was performed and should be
performed on every “at risk” routine foot care
encounter, since the patient has PVD, not only
does the examination need to support the physical
findings that correctly support the use of a Q
modifier, but a complete lower extremity vascular
examination should be performed to identify ALL
physical findings that demonstrate that the
patient has PVD. An ankle brachial index (ABI)
does not need to be performed, but specifically
for a covered systemic disease of PVD, the lower
extremity vascular examination needs to be
complete, above and beyond the identification of
class findings.

In addition to the medically appropriate history
and examination, as well as medical decision
making, it is certainly important to document the
patient’s subjective findings, or what brings the
patient to the office on this date of service. If
there are any changes in the patient’s health,
medications, etc., this should really be
documented.

With respect to the assessment, the verbiage for
the ICD-10-CM codes that qualify the patient for
“at risk” routine foot care must be documented:
The systemic disease (ICD- 10-CM code)
The DPM’s podiatric diagnoses (ICD- 10-CM codes)
Of course, the above two issues need to be
documented within the medical record as part of
the history and the examination.

Michael G. Warshaw, DPM, CPC, Lady Lake, FL

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