10 Pearls of Documentation and Coding

1. Document Medical Necessity Clearly

Always answer: Why was this service needed today?

Avoid vague statements like “painful nail.” Instead write:

“Painful dystrophic hallux nail causing difficulty ambulating and irritation in closed-toe footwear.”

Medical necessity is the #1 factor auditors look for.

2. Link the Diagnosis to the Procedure

The ICD-10 diagnosis must justify the CPT procedure.

Example:

1. Procedure: nail debridement
2. Diagnosis: onychomycosis with pain or diabetes risk

If the diagnosis does not support the procedure, reimbursement may be denied.

3. Describe Conservative Care Before Procedures

For procedures such as injections, surgery, or orthotics, document:

1. Duration of symptoms
2. Failed treatments (orthotics, NSAIDs, physical therapy)
3. Functional limitations

This is especially important for conditions like Plantar Fasciitis.

4. Use Laterality and Specificity

Always document:

1. Right vs left
2. Specific digit or anatomical structure
3. Severity

Example:
“Pain along the right plantar medial calcaneal tubercle.”

Specificity improves coding accuracy.

5. Procedure Notes Must Stand Alone

A procedure note should include:

1. Consent
2. Prep
3. Anesthesia
4. Technique
5. Findings
6. Patient tolerance
7. Post-procedure instructions

If it isn’t documented, it legally didn’t happen.

6. Avoid Cloned Notes

Copy-paste notes from the prior visit are a major audit risk.

Instead update:

1. Physical findings
2. Progression or improvement
3. Treatment decisions

Auditors look closely for identical documentation across visits.

7. Document Your Decision-Making

Evaluation and Management (E/M) coding depends heavily on medical decision-making (MDM).

Explain:

1. Differential diagnosis
2. Review of imaging
3. Risk of treatment

Example:
“Discussed surgical vs conservative management with patient.”

8. Always Document Patient Education

Risk discussions protect you medically and legally.

Examples:

1. Risks of infection
2. Recurrence rates
3. Post-operative care instructions

This documentation is critical if complications arise.

9. Be Careful With Routine Foot Care

Routine foot care is not covered by Medicare unless specific risk factors are documented such as:

1. Peripheral Neuropathy
2. Peripheral Arterial Disease
3. Diabetes Mellitus

Always document qualifying systemic conditions.

10. Your Signature Matters

Every note must include:

1. Resident signature
2. Attending physician attestation (when required)

Incomplete signatures can invalidate billing.