Checklist: Benign skin lesion removal

Documentation is for the correct beneficiary.

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 (i.e., 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 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.