Podiatry Coding & Billing Alert

Providing routine foot care, such as mycotic nail debridement, can be a real boon for business. But if the patient doesn't meet Medicare criteria for covered services, you could be stuck footing the bill.

Secure payment for routine care coding and billing with these four straight-forward steps.

Medicare recognizes the importance of preventive care for patients with systemic diseases since these patients are at a much higher risk for infections and other serious complications, notes Hoda Henein, CHBME, CPL, president and CEO, Active Management in College Point, N.Y.

Such conditions may include diabetes, pellagra, pernicious anemia, multiple sclerosis, polyneuropathy in different diseases, phlebitis and thrombophlebitis, intestinal malabsorption, or chronic kidney disease, shares Henein.

Check the carrier's Web site for a list of systemic conditions for which it may cover routine foot care, advises Paul Fehring, owner of Drs. Billing Inc., a podiatry-specific billing service in Fairfield, Ohio.

Example: If the patient has a systemic disease and a condition such as onychomycosis (110.1), candidiasis of the nail (112.3), other specified disease of nail (703.8), or unspecified disease of nail (703.9), Henein explains, Medicare will cover a nail debridement service, such as:

• 11720 -- Debridements of nail[s] by any method[s]; 1 to 5

• 11721 -- Debridements of nail[s] by any method[s]; 6 or more.

Presumed coverage: The carrier will also cover a nail debridement if the patient presents with onychomycosis or candidiasis of the nail and cellulitis and abscess of toe (681.10-681.11), ingrowing nail (703.0), difficulty in walking (719.7), or pain resulting from mycotic nails (729.5).

Policy: For a sample policy, including covered systemic conditions and documentation and billing guidelines, review the Trailblazer Health Jurisdiction 4 (local coverage determination [LCD] #L26617) statement at www.trailblazerhealth.com/Tools/Notices.aspx?DomainID=1&ID=13337. Stay tuned: Trailblazer Health currently is considering changes to their LCD on routine nail care, reports Arnold Beresh, DPM, CPC, of Peninsula Foot and Ankle Specialists PLC in Hampton, Va.

Of course, check with the LCD policy in your region/state to verify its guidelines before submitting a claim.

Keep in mind that a doctor of medicine or osteopathy must diagnose the systemic condition, such as diabetes, in order for the associated routine care to be fully covered, adds Fehring. Podiatrists can not diagnose non foot-related diseases and disorders, such as diabetes, because they can't treat the disease entity -- they can treat only the side effects, such as open wounds, adds John F. Bishop, PA-C, CPC, president and CEO, Bishop & Associates Inc. in Tampa, Fla.

Try to document the patient's diagnosis of a systemic condition by asking the patient to do one of two things:

1. Forward a copy of his or her medical record.

2. Sign a release that allows the primary care provider (PCP) to fax a statement of the patient's condition directly to your practice.

If you receive the patient by referral, remember to write the PCP's national provider identifier (NPI) in the referral box on the CMS-1500 form, says Bishop.

Important: Report the ICD-9 codes for both the presenting ailment, which is the primary diagnosis, and the systemic disease, says Bishop. For instance, for a mycotic nail debridement on a diabetic patient, report:

• 110.1 -- Dermatophytosis, of nail, onychomycosis, and

• 250.xx -- Diabetes Mellitus.

When the podiatrist treats a patient with a covered systemic condition, you must report the date the patient last saw the treating physician on the claim, notes Henein. This helps to make sure that a physician is currently monitoring the patient's condition.

6/6 rule: If, through reviewing the patient's chart, you find that the patient hasn't visited the physician who cares for her systemic condition within the last six months, remind the patient that she should visit her physician in the next six weeks before returning to see her podiatrist again, counsels Henein.

Little-known fact: Currently, Medicare's edit is to make sure the field is populated. Because Medicare's filing deadline is so vast, most doctors do not always submit their claims right away; therefore, it is not possible for Medicare to check the accuracy of the date at this time, Henein adds.

Limitations: Medicare will cover routine foot care as often as medically necessary, but no more often than every 60 days, says Henein.

Tip: Schedule visits 62 days apart to allow an extra time cushion, suggests Henein. If a patient would like his toenails trimmed more frequently than medically necessary, the doctor should notify the patient that Medicare will not cover these services and that the patient will have to pay for them.

If the podiatrist provides a separately identifiable service, you may be able to report an E/M for the encounter -- but you must remember your modifier. Whether you can report an E/M in addition to the routine care depends on the reason for the visit and how the patient presents, says Bishop. If a patient presents to the office for routine foot care, report a separate E/M encounter (99201-99215, Office or Other Outpatient Services) only if the patient had another separate presenting problem, in addition to the routine foot care, explains Richard Odom, DPM, CPC, practicing podiatrist in Spanish Fort, Ala. Select the E/M level of service based on the performed and documented medically necessary requirements.

Example: During a routine foot care service, the patient complains of a separate problem, such as a painful ankle. Then, a low-level E/M code may be appropriate, says Bishop.

When doing so, be sure to append modifier 25 (Significant and separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the office visit code, unless the patient is under a post-op global period. In that case, you would use modifier 24 (Unrelated E/M service by the same physician during a post-operative period) if there is a separate omplaint.