Podiatry SOAP Notes: Complete Guide 2026
Master podiatric documentation with comprehensive templates, diabetic foot exam protocols, Medicare compliance guidelines, CPT coding, and real clinical examples for DPMs.
3 Full Examples
Plantar Fasciitis, Diabetic Ulcer, Ingrown Nail
Podiatry SOAP Note Structure
Essential components for comprehensive foot and ankle documentation
Subjective
Patient-reported symptoms, chief complaint, and history specific to foot and ankle concerns
Key Elements:
- Chief complaint (foot/ankle pain, nail issue, wound)
- History of present illness (onset, duration, location)
- Pain assessment (location, quality, severity 0-10)
- Functional limitations (walking, standing, ADLs)
- Footwear history and occupation
- Previous treatments attempted
- Impact on mobility and quality of life
- Associated symptoms (swelling, numbness, color changes)
Sample Phrases:
Objective
Physical examination findings including gait, biomechanical assessment, and vascular/neurological testing
Key Elements:
- Gait analysis and biomechanical assessment
- Inspection (skin, nails, deformities, edema)
- Palpation findings (tenderness, masses, pulses)
- Range of motion (ankle, subtalar, first MPJ)
- Vascular assessment (pulses, ABI, color, temperature)
- Neurological exam (monofilament, vibration, reflexes)
- Dermatological findings (wounds, calluses, tinea)
- Musculoskeletal findings (strength, stability)
Sample Phrases:
Assessment
Clinical diagnosis with ICD-10 codes and severity assessment
Key Elements:
- Primary diagnosis with ICD-10 code
- Secondary diagnoses and comorbidities
- Differential diagnoses considered
- Severity assessment and classification
- Risk stratification (amputation, infection)
- Response to previous treatment
- Prognosis and functional impact
Sample Phrases:
Plan
Treatment plan including procedures, orthotics, medications, and follow-up
Key Elements:
- Treatment plan (conservative vs surgical)
- Procedures performed with CPT codes
- Prescriptions (medications, orthotics, footwear)
- Durable medical equipment ordered
- Imaging or lab tests ordered
- Referrals to specialists
- Patient education and home care instructions
- Follow-up timeline and goals
Sample Phrases:
Comprehensive Diabetic Foot Examination
Medicare-compliant documentation protocol for diabetic foot exams with LOPS assessment
Visual Inspection
Every visitComponents to Assess:
- Skin color and integrity (erythema, pallor, cyanosis)
- Presence of calluses, corns, fissures
- Nail condition (onychomycosis, ingrown, dystrophy)
- Deformities (bunions, hammertoes, Charcot)
- Edema assessment
- Hair growth patterns
- Muscle wasting
Documentation Requirements
Document location, size, and characteristics of any abnormalities
Vascular Assessment
Every comprehensive examComponents to Assess:
- Dorsalis pedis pulse (0-4+ scale)
- Posterior tibial pulse (0-4+ scale)
- Capillary refill time (<3 seconds normal)
- Skin temperature (warm/cool)
- ABI if indicated (normal 0.9-1.3)
- Dependent rubor test if PAD suspected
Documentation Requirements
Document pulse quality bilaterally; ABI if diminished or absent pulses
Neurological Assessment
Every comprehensive examComponents to Assess:
- Monofilament testing (10g Semmes-Weinstein)
- Vibration sense (128 Hz tuning fork)
- Pinprick sensation
- Proprioception (joint position sense)
- Ankle reflexes (Achilles)
- Protective sensation intact vs loss
Documentation Requirements
Document number of sites tested and protective sensation status
Risk Stratification
Annually minimumComponents to Assess:
- Risk Category 0: No LOPS, no PAD, no deformity
- Risk Category 1: LOPS ± deformity
- Risk Category 2: PAD ± LOPS
- Risk Category 3: History of ulcer or amputation
Documentation Requirements
Assign risk category and adjust follow-up frequency accordingly
Medicare Timing Requirements
Common Podiatric Conditions
Documentation guidelines, treatment protocols, and billing codes for frequently encountered conditions
Plantar Fasciitis
M72.2
STypical Presentation
Heel pain worse with first steps in morning, improves with activity
OObjective Findings
- •Tenderness at medial calcaneal tubercle
- •Pain with dorsiflexion of toes (windlass test)
- •Limited ankle dorsiflexion
- •Pes planus or cavus foot type often present
PTreatment Plan
- →NSAIDs and ice
- →Stretching protocol (gastrocnemius, plantar fascia)
- →Night splints
- →Custom orthotics or arch supports
- →Corticosteroid injection if conservative fails
- →ESWT or PRP for chronic cases
Common CPT Codes
Hallux Valgus (Bunion)
M20.10
STypical Presentation
Medial first MPJ prominence, pain with footwear, difficulty fitting shoes
OObjective Findings
- •Lateral deviation of hallux >15 degrees
- •Medial eminence prominence
- •Bursal inflammation over medial first MPJ
- •Hallux abducto valgus angle measured on X-ray
- •Pronated foot type common
PTreatment Plan
- →Conservative: Wider shoes, bunion pads, orthotics, toe spacers
- →Surgical: Bunionectomy with osteotomy (Austin, Scarf, Lapidus)
- →Post-op: NWB or PWB 4-6 weeks, surgical shoe
- →PT for ROM and strengthening
Common CPT Codes
Ingrown Toenail
L60.0
STypical Presentation
Painful nail border, often great toe, may have drainage if infected
OObjective Findings
- •Erythema and edema of nail fold
- •Nail spicule penetrating sulcus
- •Purulent drainage if infected (add L03.116)
- •Hypertrophic granulation tissue if chronic
PTreatment Plan
- →Partial nail avulsion (PNA)
- →Matrixectomy (chemical with phenol or surgical)
- →Antibiotics if cellulitis present
- →Epsom salt soaks post-procedure
- →Proper nail trimming education
Common CPT Codes
Diabetic Foot Ulcer
E11.621 (Type 2 DM with foot ulcer)
STypical Presentation
Non-healing wound on plantar foot, typically painless if neuropathic
OObjective Findings
- •Ulcer location, size (cm x cm), depth
- •Wagner grade (0-5) or UT classification
- •Wound bed appearance (granulation, slough, eschar)
- •Presence of undermining or tunneling
- •Periwound skin condition (maceration, callus)
- •Probe to bone test if osteomyelitis suspected
- •Vascular and neurological status
PTreatment Plan
- →Debridement (sharp, surgical)
- →Offloading (total contact cast, surgical shoe, felted foam)
- →Wound care (moisture balance, antimicrobials)
- →Infection management (culture, antibiotics, possible I&D)
- →Vascular surgery referral if ischemic
- →Biologics (PDGF, skin substitutes) for non-healing
Common CPT Codes
Morton's Neuroma
G57.60
STypical Presentation
Burning pain in forefoot radiating to toes, worse with tight shoes
OObjective Findings
- •Tenderness in 3rd web space (most common)
- •Positive Mulder's click (compression with lateral squeeze)
- •Pain with direct palpation plantar interspace
- •Numbness in adjacent toe surfaces
- •Ultrasound or MRI shows neuroma if obtained
PTreatment Plan
- →Conservative: Wider shoes, metatarsal pads, orthotics
- →Corticosteroid injection (alcohol sclerosing therapy alternative)
- →Surgical neurectomy if conservative fails >3-6 months
- →Post-op NWB 1-2 weeks, return to activity 4-6 weeks
Common CPT Codes
Onychomycosis
B35.1
STypical Presentation
Thickened, discolored, dystrophic toenails, often multiple nails
OObjective Findings
- •Yellow-brown discoloration
- •Subungual debris and thickening
- •Onycholysis (nail plate separation)
- •Multiple nails affected typically
- •KOH or fungal culture confirmatory
PTreatment Plan
- →Topical: Ciclopirox, efinaconazole (mild cases, limited efficacy)
- →Oral: Terbinafine 250mg daily x 12 weeks (most effective)
- →Mechanical debridement to reduce fungal load
- →Laser therapy (variable results, not typically covered)
- →Nail avulsion if severe dystrophy
- →LFTs baseline and at 6 weeks for oral antifungals
Common CPT Codes
Podiatry CPT Coding Reference
Comprehensive guide to commonly used CPT codes in podiatric practice
Office Visits
| CPT Code | Description | Notes |
|---|---|---|
| 99202-99205 | New patient visits (complexity-based) | Document MDM or time |
| 99211-99215 | Established patient visits | Most podiatry visits 99213-99214 |
Nail Procedures
| CPT Code | Description | Notes |
|---|---|---|
| 11719 | Trimming of nails, any number | Simple trimming, typically not covered for routine care |
| 11720 | Debridement of nails, 1-5 | Mycotic or dystrophic nails |
| 11721 | Debridement of nails, 6+ | Document thickness >1/3 or dystrophy |
| 11730 | Avulsion of nail plate, partial/complete | Temporary removal, simple |
| 11750 | Excision of nail and matrix, permanent | Matrixectomy for chronic ingrown |
Skin & Soft Tissue
| CPT Code | Description | Notes |
|---|---|---|
| 11055-11057 | Paring/cutting benign hyperkeratotic lesions | 1 lesion, 2-4 lesions, 4+ lesions |
| 11042-11047 | Debridement | Depth and surface area dependent |
| 10060-10061 | Incision and drainage abscess | Simple vs complicated |
| 17110-17111 | Destruction benign lesions (warts) | 1-14 lesions, 15+ lesions |
Injections
| CPT Code | Description | Notes |
|---|---|---|
| 20550 | Injection single tendon/ligament | Plantar fascia, neuroma |
| 20551 | Injection single tendon origin/insertion | Achilles, plantar fascia origin |
| 20600 | Injection small joint | MPJ, IPJ |
| 20605 | Injection intermediate joint | Ankle, subtalar |
Orthotics & DME
| CPT Code | Description | Notes |
|---|---|---|
| L3000-L3649 | Foot orthotics | Custom vs prefab, diagnosis required |
| A5500-A5514 | Diabetic shoes | Medicare 1 pair/year, 3 inserts |
| 29540 | Strapping/taping ankle/foot | Not billable with E/M same day by some payers |
Surgery - Common
| CPT Code | Description | Notes |
|---|---|---|
| 28285 | Hammertoe repair | Per digit, can code multiple |
| 28296-28299 | Bunionectomy with/without osteotomy | Complexity determines code |
| 28308 | Osteotomy calcaneus | For cavus/valgus deformity |
| 28725 | Arthrodesis subtalar joint | For PTTD stage III/IV, arthritis |
| 28080 | Excision interdigital neuroma | Morton's neuroma excision |
Diabetic Foot Care
| CPT Code | Description | Notes |
|---|---|---|
| G0245-G0247 | Initial/subsequent diabetic foot exam | Medicare-specific LOPS codes |
| 11042-11047 | Debridement diabetic wounds | Document depth and surface area |
| 97597-97598 | Wound care management | Active wound care <20cm² or ≥20cm² |
Medicare Documentation Requirements
Critical compliance requirements for routine foot care, diabetic care, and wound management
Routine Foot Care Coverage
Routine foot care NOT covered for most patients
Coverage Exceptions:
- ✓Class findings present (systemic disease affecting feet)
- ✓LOPS (Loss of protective sensation) documented
- ✓Q7-Q9 qualifying conditions
Q7-Q9 Class Findings:
- •Q7: Peripheral arterial disease (diminished pulses, claudication)
- •Q8: Sensory neuropathy (abnormal monofilament, vibration)
- •Q9: Peripheral neuropathy (documented neuropathy diagnosis)
Critical: Must document class findings in EVERY note for coverage
Diabetic Foot Care with LOPS
Covered for diabetic patients with LOPS
LOPS Documentation Criteria:
- ✓Abnormal monofilament test (10g Semmes-Weinstein)
- ✓Absent vibration sense (128 Hz tuning fork)
- ✓Absent ankle reflexes
- ✓History of ulcer or amputation
G-Codes for Billing:
G0245: Initial evaluation LOPS
G0246: Follow-up evaluation LOPS
G0247: Routine foot care with LOPS
Frequency: Every 6 months typical, can be more frequent with documentation
Therapeutic Diabetic Shoes
One pair therapeutic shoes per calendar year
Requirements for Coverage:
- •Diagnosis of diabetes (E08-E13)
- •One or more of: previous amputation, history of foot ulcer, callus, neuropathy, poor circulation, deformity
- •Certification by physician (MD/DO, not DPM)
- •Shoes fitted by qualified individual (includes DPM)
Codes: A5500 (diabetic shoe) + A5512-A5514 (inserts)
Wound Care Documentation
Required Elements Every Visit:
- •Wound location, size (length x width x depth in cm)
- •Wound bed description (% granulation, slough, eschar)
- •Drainage type and amount
- •Periwound condition
- •Debridement performed (selective vs non-selective)
- •Dressing applied
- •Medical necessity for frequency
Best Practice: Strongly recommended, becoming standard of care
Complete Podiatry SOAP Note Examples
Real-world clinical examples demonstrating comprehensive documentation
Plantar Fasciitis - Initial Visit
Plantar Fasciitis, bilateral (M72.2)
Subjective
Chief Complaint: Bilateral heel pain, worse in the morning. HPI: 45-year-old female presents with 3-month history of bilateral heel pain, worse on right. Pain is located at bottom of heels, described as sharp/stabbing. Severity 7/10 on right, 5/10 on left, worst with first steps in morning and after prolonged sitting. Improves after walking 5-10 minutes but returns with prolonged standing. Patient is a nurse, on feet 10-12 hours daily on hard floors. Aggravating factors: First steps in AM, prolonged standing, barefoot walking Alleviating factors: Rest, ice, ibuprofen Previous treatment: OTC arch supports, ibuprofen 400mg PRN (minimal relief) Footwear: Mainly athletic shoes (Nike running shoes, 2 years old), occasionally flat sandals Functional impact: Difficulty at work, unable to exercise (previously walked 3 miles daily) PMH: Obesity (BMI 32), otherwise healthy PSH: None Medications: Ibuprofen 400mg PRN Allergies: NKDA
Objective
Vitals: Ht 5'5", Wt 185 lbs, BP 128/82 GAIT: Mildly antalgic, shortened stance phase bilaterally, early heel-off INSPECTION: - Bilateral feet: No erythema, edema, or open wounds - Mild pes planus foot type bilaterally - Moderate plantar callus formation medial heel bilaterally - Mild lateral column overload callus PALPATION: - Marked tenderness medial calcaneal tubercle, right > left (8/10 and 6/10 respectively) - No tenderness along plantar fascia mid-substance - No Achilles tendon tenderness RANGE OF MOTION: - Ankle dorsiflexion: Right -5°, Left 0° (limited bilaterally) - Subtalar joint: WNL bilaterally - First MPJ dorsiflexion: 45° bilaterally (WNL) SPECIAL TESTS: - Windlass test: Positive bilaterally (reproduces pain) - Tinel's at tarsal tunnel: Negative bilaterally - Silfverskiold test: Gastrocnemius equinus bilaterally NEUROVASCULAR: - DP and PT pulses 2+ bilaterally - Sensation intact to light touch - Capillary refill <2 seconds
Assessment
1. Plantar Fasciitis, bilateral, right worse than left (M72.2) - Classic presentation with morning pain, medial tubercle tenderness - Positive windlass test - Contributing factors: Pes planus, gastrocnemius equinus, obesity, occupation 2. Gastrocnemius equinus (M21.569) - Limited ankle dorsiflexion bilaterally - Contributing to plantar fascia strain 3. Obesity (E66.9) - BMI 32, contributing factor to plantar fascia overload
Plan
TREATMENT PLAN: 1. Conservative therapy (recommend 6-12 week trial before considering injection): - Stretching protocol: Gastrocnemius/soleus stretches 3x daily, plantar fascia stretches - Icing: 15-20 minutes 2-3x daily, especially after work - NSAIDs: Ibuprofen 600mg TID with food x 2 weeks 2. Orthotics: - Prescribed custom functional foot orthotics with deep heel cup and medial posting - Will provide temporary OTC Powerstep arch supports for immediate use 3. Footwear education: - Replace current shoes (>2 years old) - Recommend cushioned stability shoes (Brooks Addiction, Asics Gel-Kayano) - Avoid flat sandals and barefoot walking - Consider Crocs or OOFOS for house shoes 4. Night splint: - Prescribed dorsiflexion night splint for right foot, wear nightly 5. Weight management discussion: - Discussed weight loss benefit for reducing plantar pressure - Recommended low-impact exercise (swimming, cycling) during healing 6. Physical therapy: Consider if no improvement in 4 weeks FOLLOW-UP: Return in 4 weeks to reassess. Call sooner if symptoms worsen. RETURN PRECAUTIONS: Seek immediate care if develop numbness, tingling, color changes, or severe swelling. Time: 45 minutes (30 minutes face-to-face counseling and coordination of care) CPT: 99203 (New patient, moderate complexity)
Diabetic Foot Exam with Wound
Type 2 DM with diabetic foot ulcer (E11.621)
Subjective
Chief Complaint: Routine diabetic foot check, small wound right foot. HPI: 68-year-old male with Type 2 diabetes (A1c 8.2% last month) presents for quarterly diabetic foot examination. Patient noticed small wound on bottom of right great toe 1 week ago, painless, no drainage initially. Today reports slight clear drainage on sock. No fever, chills, or systemic symptoms. No pain at wound site. Diabetes history: Diagnosed 15 years ago, on oral agents Previous foot complications: None, no prior ulcers or infections Footwear: Extra-depth diabetic shoes (Medicare-provided 8 months ago) Activity: Ambulates with walker due to neuropathy, balance issues Compliance: Checks feet daily, wife assists with inspection PMH: Type 2 DM, HTN, hyperlipidemia, diabetic neuropathy Medications: Metformin 1000mg BID, Glipizide 10mg daily, Lisinopril 20mg daily, Atorvastatin 40mg QHS Allergies: Sulfa (rash)
Objective
Vitals: BP 138/84, HR 76, Temp 98.4°F, Glucose (random) 165 mg/dL GAIT: Steady with walker, good clearance DIABETIC FOOT EXAMINATION: Vascular Assessment: - Right DP: 1+ (diminished), PT: 1+ (diminished) - Left DP: 1+ (diminished), PT: 1+ (diminished) - No dependent rubor, elevation pallor minimal - Skin temperature: Warm bilaterally, equal - Capillary refill: 3-4 seconds (mildly delayed) - Hair growth: Sparse on dorsum feet - No edema Neurological Assessment: - Monofilament test (10g Semmes-Weinstein): Unable to feel 7/10 sites bilaterally - LOPS confirmed - Vibration sense (128 Hz): Absent bilaterally at hallux - Ankle reflexes: Absent bilaterally - Protective sensation: LOST bilaterally Dermatological Assessment: - Right great toe plantar: 1.2 cm x 0.8 cm x 0.2 cm (superficial) ulcer at apical tip - Wound bed: 70% red granulation, 30% yellow slough - Periwound: Mild callus, no erythema or fluctuance - Drainage: Minimal serous - Probe to bone: Negative - No odor - Left foot: No wounds, mild xerosis, thick mycotic toenails all digits Musculoskeletal: - No Charcot changes, no bony prominences - Mild hammertoe deformities toes 2-5 bilaterally - Claw toe deformity right great toe (likely caused ulcer) OTHER: Onychomycosis bilaterally, all toenails thick and dystrophic
Assessment
1. Type 2 Diabetes Mellitus with diabetic foot ulcer, right hallux (E11.621) - Neuropathic ulcer, Wagner Grade 1, UT 1A - Caused by pressure from claw toe deformity and apical contact - No signs of infection currently (no cellulitis, no probe to bone) 2. Diabetic peripheral neuropathy with loss of protective sensation (E11.42) - Confirmed by abnormal monofilament, absent vibration, absent reflexes - High risk for ulceration - Risk Category 3 3. Peripheral arterial disease, lower extremities (I73.9) - Diminished but palpable pulses bilaterally - Mildly delayed capillary refill - Adequate perfusion for healing currently 4. Hammertoes, bilateral, multiple digits (M20.40) - Contributing to abnormal pressure, ulcer formation right hallux 5. Onychomycosis, bilateral feet (B35.1)
Plan
WOUND CARE: 1. Sharp debridement performed today: - Debrided 30% slough and surrounding callus - Wound now 1.5 cm x 1.0 cm x 0.2 cm (superficial) - Minimal bleeding, healthy granulation tissue base 2. Dressing protocol: - Cleanse with normal saline - Apply silver alginate (Silvercel) - Cover with foam dressing (Mepilex Border) - Change every 3 days - Provided patient/family with supplies and written instructions 3. Offloading: - Applied felted foam padding to offload apex right hallux - Instructed on use of post-op shoe for ambulation - Limit ambulation, keep foot elevated when sitting 4. Infection surveillance: - Wound culture sent (aerobic/anaerobic) as baseline - Start empiric antibiotics only if signs of infection develop - Return immediately if erythema, purulence, odor, or fever SYSTEMIC MANAGEMENT: 5. Diabetes control: - A1c 8.2% (last month) - suboptimal for wound healing - Recommend target <7% for optimal healing - Will coordinate with PCP for medication adjustment - Nutrition consult referral placed 6. Vascular: - Pulses diminished but palpable, adequate for healing currently - If wound fails to improve in 4 weeks, will order ABI and vascular surgery consult PREVENTION: 7. Footwear: - Continue diabetic shoes - Will order new custom inserts with accommodation for hammertoes 8. Nail care: - Debrided mycotic nails today (11721) - Discussed oral antifungals - patient prefers conservative management 9. Patient education: - Daily foot inspection (patient and wife) - Signs of infection to watch for - Importance of glucose control for healing - Proper offloading importance emphasized FOLLOW-UP: - Return in 1 week for wound check and dressing change - Weekly visits until healed - Consider PDGF (Regranex) if no improvement in 4 weeks - Long-term: Quarterly diabetic foot exams given high risk CPT CODES: - 99214 (Established patient, moderate complexity) - G0246 (Follow-up evaluation LOPS) - 11042 (Debridement subcutaneous tissue, <20 cm²) - 11721 (Debridement 6+ nails) - 97597 (Wound care <20 cm²)
Ingrown Toenail with Infection
Ingrown nail with infection, right great toe (L60.0, L03.116)
Subjective
Chief Complaint: Painful ingrown toenail right big toe with pus. HPI: 22-year-old male presents with 1-week history of worsening right great toe pain. Patient attempted "bathroom surgery" 3 days ago, cutting nail border. Since then, increased pain, redness, swelling, and drainage of yellow pus. Pain now 8/10, throbbing, constant. Unable to wear shoe on right foot. Difficulty walking. No fever but reports feeling "generally unwell" today. Previous episodes: Multiple ingrown nails past 2 years, usually resolves with soaking Current treatment: Epsom salt soaks last 3 days, OTC antibiotic ointment, ibuprofen Footwear: Tight dress shoes for work (bank teller), athletic shoes evenings Nail care: Cuts nails short, rounds corners PMH: Otherwise healthy PSH: None Medications: Ibuprofen 600mg TID x 3 days Allergies: NKDA
Objective
Vitals: Temp 99.8°F, BP 118/72, HR 88 INSPECTION - Right great toe: - Marked erythema and edema medial nail fold extending to proximal nail fold - Purulent drainage from medial sulcus, moderate amount - Hypertrophic granulation tissue medial nail fold (8mm elevation) - Nail spicule visible penetrating medial sulcus - Erythema extends 2cm from nail fold onto hallux - cellulitis - No lymphangitic streaking - No crepitus Left great toe: Mild medial nail fold erythema, no drainage, early ingrowth PALPATION: - Marked tenderness medial nail fold right hallux (9/10) - Fluctuance appreciated medial nail fold - No palpable lymphadenopathy inguinal region NEUROVASCULAR: - DP and PT pulses 2+ bilaterally - Sensation intact, capillary refill <2 seconds - No numbness or tingling
Assessment
1. Onychocryptosis (ingrown toenail) with paronychia and cellulitis, right hallux (L60.0, L03.116) - Infected ingrown nail with purulent drainage - Cellulitis extending beyond immediate nail fold - Hypertrophic granulation tissue secondary to chronic inflammation - Precipitated by improper nail trimming and tight footwear 2. Onychocryptosis, early, left hallux (L60.0) - Mild ingrowth, not yet infected - At risk for progression MEDICAL NECESSITY: Partial nail avulsion with matrixectomy indicated for definitive treatment and infection control.
Plan
PROCEDURE PERFORMED TODAY: Partial Nail Avulsion with Chemical Matrixectomy, Right Hallux Procedure Note: - Informed consent obtained, risks/benefits discussed including: pain, bleeding, infection, recurrence, numbness, prolonged drainage - Digital block: 3cc 1% lidocaine plain, medial and lateral digital nerves, good anesthesia obtained - Sterile prep and drape, tourniquet applied at base of toe - Vertical incision medial nail border, nail border freed and elevated - Medial 1/4 of nail plate removed to level of eponychium - Copious purulent drainage expressed and evacuated - Curettage of nail bed and matrix - 88% phenol applied to exposed matrix x 90 seconds, 3 applications - Irrigated with isopropyl alcohol - Curettage of hypertrophic granulation tissue - Hemostasis achieved, tourniquet removed - Sterile dressing applied - Tolerated well, no complications - Specimen: Nail border and granulation tissue sent for culture and sensitivity - Estimated blood loss: <5cc POST-PROCEDURE INSTRUCTIONS PROVIDED (written and verbal): - Keep dressing dry x 48 hours - Elevate foot above heart level next 48 hours - Expect drainage (clear to blood-tinged) for 2-3 weeks - Soak in Epsom salt warm water 2x daily starting day 3 - Apply antibiotic ointment after soaks - May take ibuprofen 600mg TID for pain - Activity: Rest today, may return to work tomorrow with open-toe shoe - No running/impact activity x 2 weeks MEDICATIONS: 1. Cephalexin 500mg QID x 7 days (for cellulitis) - Prescription sent electronically - Take with food, complete full course 2. Ibuprofen 600mg TID PRN pain PREVENTIVE TREATMENT - Left hallux: - Discussed definitive treatment to prevent progression - Patient elects to proceed with left PNA with matrixectomy at follow-up visit PATIENT EDUCATION: - Proper nail trimming: Straight across, not too short - Avoid tight/narrow footwear - Signs of infection requiring immediate attention FOLLOW-UP: - Return in 5-7 days for wound check, suture removal if placed, culture results - Schedule left hallux PNA at that visit if right healing well - Call sooner if: fever >101, red streaking, increased swelling, severe pain RETURN PRECAUTIONS: Provided written and verbal. Seek ER if fever, chills, red streaking, severe pain, or numbness develops. CPT CODES: - 99214 (E/M moderate complexity - separate procedure) - 11750-RT (Excision nail and matrix, permanent, right great toe) - 10060-RT (I&D abscess - paronychia) ICD-10: L60.0 (ingrown nail), L03.116 (cellulitis right toe)
Documentation Best Practices
Tips for writing better podiatry notes
Subjective
- Document pain location using anatomical terms (medial, plantar, dorsal)
- Include pain scale 0-10 for objective tracking
- Note impact on ADLs and occupation
- Record footwear type and age of shoes
- Document all previous treatments attempted
Objective
- Always include gait assessment
- Document pulses bilaterally (DP and PT) every visit
- For diabetics: monofilament test and document LOPS status
- Measure wounds in cm (length x width x depth)
- Use standardized classifications (Wagner, UT, Charcot)
Assessment
- Include ICD-10 codes with every diagnosis
- Link diagnoses to objective findings
- Stratify risk for diabetic patients (Category 0-3)
- Document medical necessity for procedures
- Note relevant comorbidities affecting treatment
Plan
- Be specific with CPT codes for procedures
- Document conservative care before surgery
- Include offloading strategies for ulcers
- Detail patient education provided
- Specify follow-up timeline and goals
Common Documentation Mistakes
Avoid these frequent errors that lead to denials and compliance issues
Inadequate vascular/neurological documentation
Consequence: Medicare denials, inability to prove medical necessity
Solution: Document pulses, monofilament test, and protective sensation status at every diabetic visit
Missing ICD-10 codes in assessment
Consequence: Billing errors, compliance issues, claim denials
Solution: Include specific ICD-10 code with each diagnosis in assessment section
Vague wound descriptions
Consequence: Cannot track healing, medical-legal risk
Solution: Measure all wounds in cm (L x W x D), describe wound bed %, document Wagner/UT grade
Not documenting medical necessity for routine care
Consequence: Medicare will deny routine nail care claims
Solution: Document class findings (LOPS, PAD, neuropathy) every visit for coverage
Incomplete diabetic foot exam documentation
Consequence: Cannot bill G-codes, compliance issues, standard of care failure
Solution: Complete all components: inspection, vascular, neurological, risk stratification
No documentation of conservative care before surgery
Consequence: Insurance denials for not meeting medical necessity
Solution: Document 4-6 weeks conservative treatment failure before surgical intervention
Frequently Asked Questions
What should be included in every podiatry SOAP note?
Every podiatry SOAP note should include: chief complaint, pain assessment (location/severity), relevant PMH (especially diabetes, vascular disease, neuropathy), bilateral pulse examination, gait assessment, specific diagnosis with ICD-10 code, treatment plan with CPT codes if procedures performed, patient education, and follow-up plan. For diabetic patients, always include vascular and neurological assessment documenting LOPS status.
How do I document a diabetic foot exam for Medicare compliance?
For Medicare compliance, document: (1) Visual inspection of both feet including skin, nails, and deformities; (2) Vascular assessment with bilateral pulse palpation and skin characteristics; (3) Neurological assessment with monofilament test (10g Semmes-Weinstein) documenting protective sensation status; (4) Risk stratification (Category 0-3); (5) Patient education provided. Use G-codes (G0245-G0247) and document medical necessity for routine care by noting class findings every visit.
What are the medical necessity requirements for routine foot care?
Medicare does not cover routine foot care UNLESS the patient has class findings documented: Q7 (peripheral arterial disease with diminished pulses), Q8 (sensory neuropathy from diabetes or other systemic disease), or Q9 (peripheral neuropathy). You must document these findings in every note to justify coverage. For diabetic patients with LOPS (Loss of Protective Sensation), routine care is covered under G-codes with proper documentation.
How should I document wound care for proper coding?
Document wound location using anatomical terms, measure in centimeters (length x width x depth), describe wound bed composition (% granulation, slough, eschar), note presence of undermining or tunneling, assess periwound skin, document drainage type and amount. Use wound classification systems (Wagner 0-5 or UT classification). For debridement coding, document depth (skin, subcutaneous, muscle, bone) and surface area (<20 cm² or ≥20 cm²). Include photographs when possible.
What CPT codes are most commonly used in podiatry?
Common podiatry CPT codes include: 99211-99215 (office visits), 11720-11721 (nail debridement), 11730/11750 (nail avulsion), 11055-11057 (callus debridement), 20550 (injection tendon/ligament), 11042-11047 (wound debridement), 97597-97598 (wound care), 28285 (hammertoe repair), 28296-28299 (bunionectomy), G0245-G0247 (diabetic foot exams). Always pair with appropriate ICD-10 codes and document medical necessity.
How do I document gait and biomechanical assessment?
Document gait phase abnormalities (antalgic, shortened stance, early/late heel-off, toe-walking), foot type (pes planus, pes cavus, neutral), forefoot/rearfoot alignment, ankle range of motion (dorsiflexion/plantarflexion), first MPJ ROM, subtalar joint motion, muscle strength testing when relevant. Note functional limitations. Use terms like "compensated rearfoot varus" or "rigid forefoot valgus" for biomechanical diagnoses. Gait analysis justifies need for orthotics and biomechanical interventions.
What documentation is needed for custom orthotics?
Document: (1) Biomechanical examination findings (foot type, gait abnormalities, ROM limitations); (2) Diagnosis requiring orthotic intervention with ICD-10 code; (3) Medical necessity statement explaining why orthotic is needed; (4) Failed conservative treatment if applicable; (5) Prescription details (type of orthotic, materials, posting/modifications); (6) Patient education on use and break-in period. For diabetic orthotics, must document LOPS and foot deformities. Keep casting/impression records.
How can AI help with podiatry documentation?
AI documentation tools like PatientNotes can capture your patient encounters and generate comprehensive SOAP notes specific to podiatry. The AI can prompt you to include essential elements like bilateral pulses, monofilament testing for diabetics, wound measurements, and gait assessment. It ensures you document medical necessity for Medicare patients, includes appropriate ICD-10 and CPT codes, and maintains compliance with specialty-specific requirements. This saves 10-15 minutes per patient while improving documentation quality.
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