Podiatry Coding & Billing Alert

Hint: Medicare has a systemic condition exception to its routine foot care policy.

Medicare has a very specific policy regarding whether it will reimburse routine foot care for patients. However, there are exceptions to this policy, and the nuances can be overwhelming.

Check out the following FAQs and pave your way to cleaner claims today.

FAQ 1: Does Medicare reimburse for routine foot care services?

Answer: No. Medicare generally does not cover routinefoot care services, according to Michele Poulos, provider outreach and education consultant at National Government Services (NGS), in the webinar "Routine Foot Care and Debridement of Nails."

Medicare considers the following foot care services routine, according to the Medicare Benefit Policy Manual in chapter 15, section 290.B.2:

• The cutting or removal of corns and calluses
• The trimming, cutting, clipping, or debriding of nails
• Other hygienic and preventive maintenance care, such as:​

            o Cleaning and soaking the feet
            o Using skin creams to maintain skin tone of either ambulatory or bedfast patients
            o Any other service performed in the absence of localized illness, injury, or symptoms involving the foot.

FAQ 2: What is the systemic condition exception to Medicare's routine foot care policy?

Answer: An exception to Medicare's routine foot care policy is when the patient has a systemic condition like a metabolic, neurologic, or peripheral vascular disease, Poulos says.

"Accordingly, foot care that would otherwise be considered routine may be covered when systemic condition(s) result in severe circulatory embarrassment or areas of diminished sensation in the individual's legs or feet," adds the Medicare Benefit Policy Manual in chapter 15, section 290.C.

Caution: "The systemic condition must be of sufficient severity that performance of such services by a nonprofessional person would put the patient at risk," Poulos says.

FAQ 3: In the absence of a systemic condition, can treatment of mycotic nails be covered?

Answer 3: Yes, in the absence of a systemic condition, treatment of mycotic nails may also be covered, per the Medicare Benefit Policy Manual in chapter 15, section 290.

However, there are specific rules for the treatment of mycotic nails for both ambulatory and nonambulatory patients.

For ambulatory patients, the physician who attends to the patient's mycotic condition must document the following:

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

For nonambulatory patients, the treatment of mycotic nails is only covered when the physician attending the patient's condition documents:

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

FAQ 4: What are some systemic conditions that may justify coverage for routine foot care?

Answer: The Medicare Benefit Policy Manual in chapter 15, section 290.D includes a list of various systemic conditions that may justify coverage for routine foot care. Some of the included diagnoses in this list are Buerger's disease (thromboangiitis obliterans), chronic thrombophlebitis, and diabetes mellitus.

Note: You can check out the Medicare Policy Manual for this list of systemic conditions. But, you should know that the manual stipulates, "Although not intended as a comprehensive list, the following metabolic, neurologic, and peripheral vascular diseases (with synonyms in parentheses) most commonly represent the underlying conditions that might justify coverage for routine foot care."

Don't miss: The manual tells you to pay attention to the conditions in the list that are marked by asterisks because with those diseases, routine foot care will only be covered if the patient is under the active care of a physician who documents the patient's condition.

FAQ 5: What is an LCD?

Answer: Local coverage determinations (LCDs) are Medicare regulations formulated on the concept of a reasonable and necessary service, according to Judy Brown, CPC, provider outreach and education consultant at NGS.

MACs create LCDs based on the CMS Internet-only Manuals (IOMs) and hone down and make them specific to their locality, Brown says.

LCDs cannot contradict the CMS IOMs and they list the procedure codes, diagnosis codes, and policy, etc. you need to know for certain services, Brown adds.

For example, the NGS LCD for routine foot care and debridement services is LCD L33636.

Keeping track of your payers LCDs is crucial to successful reporting, according to Brown.

Tip: Brown recommends printing out relevant LCDs, tabbing sections, and highlighting them for clarity.

FAQ 6: What do class findings have to do with routine foot care coverage?

Answer: When evaluating whether routine foot care services can be reimbursed, there is a presumption that the services may be covered with the evidence available of certain physical and or clinical findings. According to Poulos, the following findings must be documented and maintained in the patient's record:

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 as evidenced by any three:​

            o Hair growth (decrease or absence)
            o Nail changes (thickening)
            o Pigmentary changes (discoloration)
            o Skin texture (thin, shiny)
            o Skin color (rubor or redness).

Class C Findings

• Claudication
• Temperature changes
• Edema
• Paresthesias (abnormal spontaneous sensations in the feet)
• Burning.

This presumption of coverage can be applied when the podiatrist rendering the routine foot care has identified the following, according to the Medicare Benefit Policy Manual in chapter 15, section 290.F:

• One Class A finding;
• Two Class B findings; or
• One Class B and two Class C findings.