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Last Modified: 8/10/2022 Location: FL, PR, USVI Business: Part A, Part B

Checklist: Surgical services: CPT 37227- vascular stenting lower extremities and 37229- endovascular revascularization documentation

This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for surgery-revascularization procedures of lower extremity. It is not intended to replace the published guidelines. Health care providers retain responsibility to submit complete and accurate documentation.

Documentation requirements
Documentation is for the correct beneficiary.
Documentation is for the correct date of service.
Documentation contains a valid and legible signature.
Documentation that includes evidence of a qualifying medical condition/disease(s) to support Medicare coverage requirements as outlined in LCD L33763.
The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
Documentation includes evidence of a thorough physical examination to support the condition(s) being treated.
This documentation should also include, but is not limited, to the following (as applicable to the patient’s episode of care):
Relevant medical history (e.g., claudication, critical limb ischemia)
Vascular physical examination (including measurement of the ankle-brachial index)
Previous noninvasive diagnostic evaluation(s)
Detailed summary of the angiography report
Detailed summary of the procedure/operative report
Documentation that includes a procedure note with the following information, if applicable:
Thorough/detailed description of the procedure being performed (beyond simple statements)
Location of each site treated
Type of anesthesia utilized
If applicable and required, submitted documentation should include a beneficiary waiver of liability.
This material is proprietary information of First Coast Service Options, Inc. This material may not be duplicated, in whole or in part, for profit-making purposes. First Coast and its staff make no representation, warranty or guarantee this compilation of Medicare information is not error-free, nor that use of this information will prevent differences of opinion or disputes with Medicare.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.