23 Miss. Code. R. 203-6.4 - Documentation

Medicaid requires podiatry providers to maintain auditable records that will substantiate the services provided. At a minimum, the records must contain the following on each patient:

A. Date(s) of service,

B. Patient's presenting complaint(s),

C. Patient's history and physical findings,

D. Treatment rendered, including: frequency of treatment, proposed length of treatment, and progress reports documenting the patient's progress with the treatment, and prognosis,

E. Narrative or operative report specific for procedure, type of anesthesia used for the procedure,

F. Clinical evidence of all conditions,

G. Accurate diagnosis codes to reflect all conditions,

H. X-rays ordered or obtained,

I. Full name and address of the MD/DO treating patient for a systemic condition and date of last visit with that MD/DO and must be within last six (6) months. Medical necessity must document the local pathology of the foot that requires professional intervention, identify complicating factors,

J. Full description of the clinical symptoms of the systemic condition,

K. Site of each wart, size, method of treatment or surgical removal,

L. Medical necessity of therapy, specific modality, or procedure, frequency of therapy, proposed length of therapy, and progress reports of patient's therapy,

M. Complicating conditions of the nail that limits ambulation, pain, or secondary infection result in thickening and dystrophy of the infected toenail plate,

N. Warts removed by cautery must include the number of lesions removed, their location, size and type of cautery used. If removed by surgical excision the operative note and pathology report on the excised tissue including number of specimens, their location, size, and any/all microscopic findings,

O. Nerve block injections must be reasonable and medically necessary and must indicate that a more conservative therapy has not been effective, must describe patient's clinical state, history, physical findings, laboratory and other tests, identification of the problem, including diagnosis, precipitating events, quantity and quality of pain, test results, response to previous therapy, the procedure performed, including area injected, the substance(s) injected, and the dosage of the substance(s),

P. Diagnosis(es) to substantiate all treatments/procedures,

Q. The name, strength, dosage, route (intramuscular, intravenous, subcutaneous, oral, and topical, etc.), date and time, indication for, and the administration of all medications administered to the patient,

R. Patient's or guardian's refusal of services, if applicable,

S. Photographs, if applicable, must be prints, not slides, and include the patient's name and date of service, to document severe paronychia, persistent, recurrent infections, clinical evidence of systemic conditions related to the foot, mycotic nails, severity of ulcers of the foot and progression of ulcer(s), deformities such as hammertoe, traumatic injuries, severity of ingrown toenails or ingrown toenail condition on toes other than big toe,

T. Description(s) of wound(s), ulcer(s), etc., if applicable, including size, appearance, and location for each date of service, and

U. Podiatrist signature.

Notes

23 Miss. Code. R. 203-6.4

Miss. Code Ann. § 43-13-121