Revenue Cycle Insider

Patient and practitioner education are key to successful claim payment.

When it comes to foot care, medical providers, Medicare, and other payers often use terms like “routine foot care” or “at-risk foot care,” with various acronyms depending on the doctor, practice, and location. But what does routine foot care really involve?

Continue reading to discover what counts as routine foot care and what does't, it may save you the headaches of denied claims.

According to Centers for Medicare & Medicaid Services (CMS), procedures like nail and callus care are considered “routine” when there's no pain or systemic condition that would put the patient at risk if a nonprofessional provided the care. This means that it is deemed safe for a patient to see a pedicurist for treatment, but because not all pedicures are safe for those with systemic conditions, Medicare will cover routine treatment only when performed by a qualified medical professional. Coverage extends to conditions like neuropathy, vascular insufficiency, diabetic retinopathy, and even pain.

If you're in a Noridian jurisdiction, Medicare even covers treatment for painful calluses. Here's some great news — when these seemingly routine treatments are efficiently scheduled, they don't just benefit the patient; they can also make a significant positive impact on the bottom line of your practice.

Managing the Coding of Foot Care

When discussing at-risk foot or routine foot care, these are the most commanly used CPT^® codes for calluses and nail treatments:

• 11055 (Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion)
• 11056 ([…] 2 to 4 lesions)
• 11057 ([…] more than 4 lesions)
• 11719 (Trimming of nondystrophic nails, any number)
• 11720 (Debridement of nail(s) by any method(s); 1 to 5)
• 11721 ([…] 6 or more)

Debridement is defined as reduction in the bulk of the nail, while trimming is defined as reduction in length.

Remember: Treatment of calluses can be coded along with treatment of the nails with appropriate medical documentation and modifiers despite being considered mutually exclusive according to National Correct Coding Initiative (NCCI) edits. For example, if a callus is trimmed on the interphalangeal joint (IPJ) or distal to the IPJ of a toe and a nail is treated as well, the debridement of the nail on the same toe cannot be submitted separately for reimbursement. 

The trimming of nails described as dystrophic is coded using HCPCS code G0127 (Trimming of dystrophic nails, any number). 

When five or fewer nails are debrided and the remaining nails are trimmed, 11720 and 11719 or HCPCS code G0127 can be coded together and paid with the appropriate modifier 59 (Distinct procedural service) or XS (Separate structure, a service that is distinct because it was performed on a separate organ/structure) added to the claim. When coding 11720 and 11719 together, 11719 is a column 1 code to 11720, and thus the 59 or XS modifier would be appended to 11720.  Conversely, 11720 is column 1 to G0127 and the 59 or XS modifier would then be attached to G0127.

A possible coding scenario could be four nails debrided, and six non-dystrophic nails trimmed. That would be coded as 11719 and 11720 with modifier XS or 59. A second scenario could be 5 calluses trimmed, 6 nails debrided, and 4 nails trimmed. This second scenario would be coded as 11057 and 11721 with XS or 59.

Keep in mind: It is important to note that these codes will not be covered unless medically necessary. Medical necessity is based on many things, including diagnosis codes, class findings, and risk. 

Understand What ‘Routine’ Covers

Interestingly, patients are often unaware of these benefits. In fact, the Medicare coverage website for beneficiaries states, “Medicare doesn’t usually cover routine foot care.” It then goes on to define routine foot care as including the cutting of corns/calluses and trimming/cutting of nails. Patients generally assume that this treatment is not covered, period. Because Medicare guidelines state that it covers foot exams for diabetics every six months, many patients are led to believe they can only get treatment twice a year, regardless of whether they are diabetic or not.

This is an unfortunate situation and requires patient education to correct the misinformation. The word “usually” has a significant impact on the statement of coverage, and that one word has medical providers turning away patients because they, too, believe callus and nail care is noncovered. 

Know Why Your Medicare Administrative Carrier Matters

It's important to keep in mind that each Medicare Administrative Contractor (MAC) has its own specific coverage criteria. For example, some carriers will cover nail treatment with a diagnosis of edema and others with a diagnosis of unsteadiness of the feet. Yet, some are so strict that they need the thickness of the nail to be documented in millimeters.

Keep this in mind when asking a specific payer why a claim was denied. For every code set there are different coverage criteria for each Medicare carrier, which extends to Medicare Advantage plans. For example, carriers such as Palmetto GBA require documented class findings, and a Q modifier such as Q7 (one class A finding), Q8 (two class B findings), or Q9 (one class B and two class C findings) for all systemic conditions; whereas others such as Noridian require the class finding modifier only for circulatory conditions. 

Tonia Silva, CPC, CPPM, CPMA, Medical Coding & Billing Consultant,
Owner of Enhanced Billing Solutions