Routine Foot Care Visit (Medicare)

Date/Time: [Date and time of encounter]

Patient Name: [Full name]

DOB: [Date of birth]

MRN: [Medical record number]

Service Location: [office / facility / home / SNF / ALF]

Rendering Clinician: [Name, credentials]

Visit Type: Routine Foot Care (Medicare) – [scheduled maintenance / problem-driven]

Chief Concern

[Brief statement anchoring medical necessity, such as painful thickened toenails, painful plantar callus, or at-risk routine nail/callus care due to systemic disease] (One to two sentences maximum; may include a short patient quote if it adds specificity about pain or functional limitation.)

Medicare Coverage Determination

(This section must be completed for every encounter. If required information is not available, document as "not documented/verified" and default to non-covered unless subsequently verified.)

• Coverage Basis: [A: Systemic condition with qualifying class findings / B: Mycotic nail exception without systemic disease (if applicable per MAC policy) / C: Necessary and integral to otherwise covered foot service / D: Non-covered routine foot care (patient self-pay)] (Default to D if A–C cannot be supported by documented findings.)
• Qualifying Systemic Condition(s): [Specific active systemic disease(s) creating hazardous self-care risk] (Only complete if Coverage Basis A. Confirm condition is active and relevant to foot risk today; do not infer solely from problem list.)
• Active Care Verification: [Name of MD/DO managing the complicating disease] | [Date last seen for that condition] (If unknown or unverified, state "not documented/verified" and proceed as non-covered unless later verified.)
• Class Findings:
  • Class A: Nontraumatic amputation of foot or integral skeletal portion: [yes / no] [If yes: side and level]
  • Class B:
    • Dorsalis pedis pulse: R [present / absent / 0-2+] | L [present / absent / 0-2+]
    • Posterior tibial pulse: R [present / absent / 0-2+] | L [present / absent / 0-2+]
    • Trophic changes: Hair loss [present / absent; laterality] | Skin texture changes [present / absent; laterality] | Skin color changes [present / absent; laterality] | Nail trophic changes [present / absent; laterality]
  • Class C: Claudication [present / absent; laterality] | Temperature changes [present / absent; laterality] | Edema [present / absent; laterality] | Paresthesias [present / absent; laterality] | Burning [present / absent; laterality]
  • Applicable Q-Modifier: [Q7 (Class A) / Q8 (two Class B findings) / Q9 (one Class B plus two Class C findings) / none] (Only select if supported by objective findings documented this encounter or by reference to a prior exam that remains accurate; if referencing prior exam, cite date.)
• Service Frequency: Last routine foot care: [Date or "none documented"] | Planned follow-up interval: [Interval] (If interval < 60 days, provide brief justification: [Medical necessity rationale].)

History

HPI: [Symptom drivers and functional impact including pain location/severity, difficulty walking, shoe irritation, inability to trim safely; self-care limitations creating hazard such as vision impairment, neuropathy, tremor, anticoagulation, limited mobility; red flag screen for drainage, odor, ulceration, spreading redness, fever]

Safety-Relevant Medications: [Anticoagulants/antiplatelets, immunosuppressants, relevant allergies especially to topical agents]

Pertinent Medical History: [Diabetes, PAD/PVD, neuropathy, ESRD, history of foot ulcer or amputation, venous disease, Charcot changes, smoking status if relevant]

Examination

(Document with bilateral notation where applicable.)

• Vascular: DP pulses R [0-2+] L [0-2+] | PT pulses R [0-2+] L [0-2+] | Capillary refill [seconds; R/L] | Skin temperature [warm / cool / cold; R/L] | Dependent rubor/pallor [present / absent; laterality] | Edema [location and severity] | Trophic changes [hair distribution, skin texture, skin color, nail trophic changes]
• Neurologic: Protective sensation by monofilament [intact / diminished / absent; sites tested] | Paresthesias/burning [present / absent; laterality]
• Skin and Nails:
  • Nails (identify each by toe R1–R5, L1–L5): [Toe ID]: [thickness], [dystrophy], [subungual debris], [incurvation], [tenderness], [mycotic features], [color changes] (Repeat for each nail examined.)
  • Hyperkeratotic lesions: [Number] | [Exact location(s) using plantar/medial/lateral landmarks] | [Size(s)] | [Painful: yes / no] | [Fissuring/hemorrhage: present / absent] | [Pre-ulcerative features: present / absent]
  • Ulcers/wounds/infection: [Present / absent] (If present: [location, size, depth, drainage, odor, erythema, warmth, fluctuance])
  • Interdigital: [Web spaces involved, maceration, tinea, bacterial changes] (Omit if unremarkable.)
• Musculoskeletal: [Deformities affecting pressure distribution: hammertoes, bunions, Charcot changes, prominent metatarsal heads] (Omit if unremarkable.)

Assessment

1. [At-risk status due to qualifying systemic condition with peripheral complications and brief clinical rationale]
2. [Class finding summary with coverage determination, e.g., "Absent PT pulse bilaterally with trophic changes meets Class B criteria for Q8"] (Only state Q-modifier if supported by documented findings.)
3. [Nail pathology: dystrophic/onychomycotic nails, pain, functional impact]
4. [Hyperkeratotic lesions: location, pain, pre-ulcerative features]
5. [Other significant findings: new ulcer, infection, or other issues] (Omit if none.)

Plan

• Risk counseling: [Daily inspection, moisturization avoiding interdigital spaces, footwear guidance, when to seek urgent care]
• Care coordination: [Communication with PCP/diabetes team/vascular as indicated] (Omit if not applicable.)
• Follow-up: [Interval] (If sooner than 60 days, document rationale.)
• Escalation triggers reviewed: [New ulcer, drainage, increasing redness, systemic symptoms]

Procedure

Nail Care

• Indication: [Pain/functional impairment/hazard due to systemic disease and class findings]
• Consent: Verbal consent obtained; risks discussed.
• Procedure Type: [trimming/clipping / debridement with reduction of thickness and removal of subungual debris]
• Nails Treated: [List each nail by identifier (R1, R2, L1, etc.) with key characteristics: thickened/dystrophic/painful/incurvated]
• Technique: [Instruments and method]
• Hemostasis/Complications: [None / describe]
• Patient Tolerance: [Tolerated well / describe]
• Aftercare: [Instructions given; warning signs reviewed]

Corn/Callus Paring

(Include only if performed.)

• Indication: [Pain/pressure relief/pre-ulcerative risk]
• Consent: Verbal consent obtained; risks discussed.
• Lesions Treated: [Number and exact anatomical location(s)]
• Technique: [Scalpel / curette], [depth of debridement], [pre-ulcerative changes: present / absent]
• Hemostasis/Complications: [None / describe]
• Patient Tolerance: [Tolerated well / describe]
• Aftercare: [Instructions given; warning signs reviewed]

Non-Covered Service Documentation

(Include only if Coverage Basis is D.)

• Status: Routine foot care not meeting Medicare coverage exceptions.
• ABN: [Offered: yes / no] | Patient election: [proceed self-pay / decline service]
• Financial Responsibility: Patient informed and agrees.

Clinician Signature

[Rendering clinician name, credentials, signature] | [Date and time signed]