AnnexMed - Medical billing and Revenue cycle management companyAnnexMed - Medical billing and Revenue cycle management companyAnnexMed - Medical billing and Revenue cycle management company
1-866-780-0669
9am - 8pm (EST)
New Jersey, USA

Podiatry Coding: Routine Foot Care Exceptions and Exclusions

Podiatry Coding

In podiatry coding routine foot care is not a covered Medicare benefit. Medicare assumes that the patient or caregiver will perform these services by themselves, and therefore, these services are excluded from coverage, with certain exceptions. The Centers for Medicare & Medicaid Services (CMS) has established national-level guidelines governing routine foot care and treatment of mycotic nails.

Services that normally are considered routine and not covered by Medicare include the following:

  • The cutting or removal of corns and calluses;
  • The trimming, cutting, clipping, or debriding of nails; and
  • Other hygienic and preventive maintenance care, such as cleaning and soaking the feet, the use of skin creams to maintain skin tone of either ambulatory or bedfast patients, and any other service performed in the absence of localized illness, injury, or symptoms involving the foot.

Exceptions to Routine Foot Care Exclusion

Necessary and Integral Part of Otherwise Covered Services:

In certain circumstances, services ordinarily considered to be routine may be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of ulcers, wounds, or infections

Treatment of Warts on Foot:

The treatment of warts (including plantar warts) on the foot is covered to the same extent as services provided for the treatment of warts located elsewhere on the body.

Presence of Systemic Condition:

The presence of a systemic condition such as metabolic, neurologic, or peripheral vascular disease may require scrupulous foot care by a professional that, in the absence of such a condition(s), would be considered routine (and, therefore, excluded from coverage).

Accordingly, foot care that would otherwise be considered routine may be covered when systemic conditions result in severe circulatory embarrassment or areas of diminished sensation in the individual’s legs or feet.

In these instances, certain foot care procedures that otherwise are considered routine (e.g., cutting or removing corns and calluses, or trimming, cutting, clipping, or debriding nails) may pose a hazard when performed by a nonprofessional person on patients with such systemic conditions.

Mycotic Nails:

In the absence of a systemic condition, treatment of mycotic nails may be covered.

The treatment of mycotic nails for an ambulatory patient is covered only when the physician attending the patient’s mycotic condition documents that

  • there is clinical evidence of mycosis of the toenail, and
  • the patient has marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

The treatment of mycotic nails for a nonambulatory patient is covered only when the physician attending the patient’s mycotic condition documents that

  • there is clinical evidence of mycosis of the toenail, and
  • the patient suffers from pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

Systemic Conditions That Might Justify Coverage:

The most common diagnoses that can represent the underlying conditions to justify coverage as exceptions to routine foot care exclusions are:

  • Diabetes mellitus *
  • Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis)
  • Buerger’s disease (thromboangiitis obliterans)
  • Chronic thrombophlebitis *
  • Peripheral neuropathies involving the feet –

Associated with malnutrition and vitamin deficiency *

    • Malnutrition (general, pellagra)
    • Alcoholism
    • Malabsorption (celiac disease, tropical sprue)
    • Pernicious anemia

    Associated with carcinoma *

    Associated with diabetes mellitus *

    Associated with drugs and toxins *

    Associated with multiple sclerosis *

    Associated with uremia (chronic renal disease) *

    Associated with traumatic injury

    Associated with leprosy or neurosyphilis

    Associated with hereditary disorders

    • Hereditary sensory radicular neuropathy
    • Angiokeratoma corporis diffusum (Fabry’s)
    • Amyloid neuropathy

When the patient’s condition is one of those designated by an asterisk (*), routine procedures are covered only if the patient is under the active care of a doctor of medicine or osteopathy who documents the condition.

Supportive Devices for Feet

Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics.

Presumption of Coverage

In evaluating whether the routine services can be reimbursed, a presumption of coverage may be made where the evidence available discloses certain physical and/or clinical findings consistent with the diagnosis and indicative of severe peripheral involvement. For purposes of applying this presumption, the following findings are pertinent:

Class A Findings

Nontraumatic amputation of foot or integral skeletal portion thereof.

Class B Findings

  • Absent posterior tibial pulse
  • Absent dorsalis pedis pulse
  • Advanced trophic changes (at least three of the following):
    • hair growth (decrease or absence)
    • nail changes (thickening)
    • pigmentary changes (discoloration)
    • skin texture (thin, shiny)
    • skin color (rubor or redness) (Three required)

Class C Findings

  • Claudication
  • Temperature changes (e.g., cold feet)
  • Edema
  • Paresthesias (abnormal spontaneous sensations in the feet); and
  • Burning

The presumption of coverage may be applied when the physician rendering the routine foot care has identified:

  1. A Class A finding (Submit modifier Q6)
  2. Two of the Class B findings; (Submit modifier Q7) or
  3. One Class B and two Class C findings (Submit modifier Q8)

Cases evidencing findings falling short of these alternatives may involve podiatric treatment that may constitute covered care and should be reviewed by the intermediary’s medical staff and developed as necessary. For purposes of applying the coverage presumption where the routine services have been rendered by a podiatrist, the A/B MAC (B) may deem the active care requirement met if the claim or other evidence available discloses that the patient has seen an M.D. or D.O. for treatment and/or evaluation of the complicating disease process during the 6-month period prior to the rendition of the routine-type services. The A/B MAC (A) may also accept the podiatrist’s statement that the diagnosing and treating M.D. or D.O. also concurs with the podiatrist’s findings as to the severity of the peripheral involvement indicated.

Application of Foot Care Exclusions to Physician’s Services:

The exclusion of foot care is determined by the nature of the service. Thus, payment for an excluded service should be denied whether performed by a podiatrist, osteopath, or a doctor of medicine, and without regard to the difficulty or complexity of the procedure.

When an itemized bill shows both covered services and noncovered services not integrally related to the covered service, the portion of charges attributable to the noncovered services should be denied. (For example, if an itemized bill shows surgery for an ingrown toenail and also removal of calluses not necessary for the performance of toe surgery, any additional charge attributable to removal of the calluses should be denied.)

In reviewing claims involving foot care, the A/B MAC (B) should be alert to the following exceptional situations:

  • Payment may be made for incidental noncovered services performed as a necessary and integral part of, and secondary to, a covered procedure. For example, if trimming of toenails is required for application of a cast to a fractured foot, the A/B MAC (B) need not allocate and deny a portion of the charge for the trimming of the nails. However, a separately itemized charge for such an excluded service should be disallowed. When the primary procedure is covered, the administration of anesthesia necessary for the performance of such a procedure is also covered.
  • Payment may be made for initial diagnostic services performed in connection with a specific symptom or complaint if it seems likely that its treatment would be covered even though the resulting diagnosis may be one requiring only noncovered care.

The name of the M.D. or D.O. who diagnosed the complicating condition must be submitted with the claim. In those cases, where active care is required, the approximate date the beneficiary was last seen by such physician must also be indicated.

Documentation Requirements:

  • When a Q7, Q8, or Q9 modifier is used, the provider must document in the medical record the appropriate signs and symptoms as outlined in Class Findings A, B, and/or C along with the complicating condition(s).
  • When the patient has a systemic condition that might justify coverage and the services are performed by a podiatrist, the medical record must contain the name of the treating and/or diagnosing doctor of medicine or osteopathy.

References:

CMS Internet Only Manual (IOM) Pub. 100-02, Benefit Policy Manual, Chapter 15, Section 290

Previous Post