Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 6 - Podiatry › Rule 23-203-6.4 - Documentation

Current through June 25, 2024
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.
Miss. Code Ann. §
										43-13-121