Podiatry and Routine Foot Care Documentation Requirements

It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:

Check
Brief Description
Operative / procedure report
Practitioner, nurse, and ancillary progress notes
Documentation to support a systemic condition, neuropathy, vascular impairment, onychogryphosis and/or onychauxis
Evidence to support active care of a qualifying systemic condition within 6-months of rendering foot care services
Evidence to support the beneficiary is at significant risk if the service is rendered by anyone other than a DPM, MD, DO, or NPP
Clinical evidence of 1) mycotic nails, and 2) marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate
Evaluation of foot structure, vascular and skin integrity
Debridement of nails with E&M
Documentation supporting the diagnosis code(s) required for the item(s) billed
Documentation to support the code(s) and modifier(s) billed
List of all non-standard abbreviations or acronyms used, including definitions
Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
Any additional documentation to support the reasonable necessity of the service(s) performed
Advance Beneficiary Notice
Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
Signature attestation and credentials of all personnel providing services
If an electronic health record is utilized, include your facility's process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician

Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part B Claim Review for detailed information about each of these contractors.

Documentation Submission

Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.

View the Podiatry webpage for additional information and resources.

Last Updated Mar 21 , 2025

Documentation Requirements Disclaimer

The documentation requirements contents/references provided within this section were prepared as educational tools and are not intended to grant rights or impose obligations. Use of these documents are not intended to take the place of either written law or regulations.

The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered.

Important that physician intent, physician decision and physician recommendation to provide services derived clearly from the medical record and properly authenticated.

The submission of these records shall not guarantee payment as all applicable coverage requirements must be met.