Checklist: Skin lesion removal
This checklist is intended to provide health care providers with a reference for use when responding to additional documentation requests for wound care. Healthcare providers retain responsibility to submit complete and accurate documentation.
| Check | Documentation description |
|---|---|
| Documentation is for the correct date(s) of service. | |
| Documentation contains a valid and legible signature for the provider performing the service(s), which follows CMS Signature Guidelines for Medical Review Purposes | |
| Documentation supports the selected ICD-10-CM code(s) billed for the service(s). | |
| Documentation supports a medically reasonable and necessary service(s) that includes relevant pre-procedure documentation (e.g., history and physical examination, progress notes, pre-operative examination, beneficiary consent / treatment option discussion, laboratory / diagnostic testing results, etc.). | |
| Documentation includes applicable operative / procedure note for the service(s) performed. | |
| Documentation includes an Advanced Beneficiary Notice (ABN) of non-coverage was provided (if applicable and required). | |
| Any additional documentation to support medical necessity or any applicable policy guidelines for the service(s) billed. |
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.