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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 additional documentation requests for Nail cutting/paring and debridement services It is not intended to replace the published guidelines. Health care providers retain responsibility to submit complete and accurate documentation.

Check Documentation description
  Documentation is for the correct beneficiary and date of service.
  Documentation is complete, legible, signed and dated by the physician or clinician.
  Documentation that includes evidence of a qualifying medical condition / disease(s) to support Medicare coverage requirements for routine foot care exclusion.
  Documentation demonstrates the medical necessity of each service considering the patient's usual activities including being actively seen by a primary care provider.
  Documentation includes evidence of a thorough physical examination to support the condition(s) being treated.
 

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
 

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
  Documentation supporting an order or request by the patient / patient's family for foot-care services provided in a nursing facility, if applicable.
 

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
  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.