Podiatry Coding & Billing Alert

Question: What is Medicare’s policy for covering routine nail care?

Hawaii Subscriber

Answer: Medicare does not normally provide coverage for routine foot care, including the care of nails. Medicare assumes that patients or their caregivers will perform these services themselves.

Foot care definition: Medicare interprets routine foot care to include any foot care services performed in the absence of localized illness, injury, or symptoms involving the foot. Medicare generally does not provide coverage for routine nail care such as clipping, trimming, or debridement of nails (including trimming of mycotic nails).

Exception: Medicare will cover routine foot care when systemic conditions, like metabolic, neurological, or peripheral vascular disease, result in severe circulatory embarrassment or areas of diminished sensation in the individual’s legs or feet. Under those conditions, foot care that is otherwise considered routine may be deemed as reasonable and medically necessary.

Systematic conditions: Systemic conditions that warrant coverage for routine nail care include diabetes mellitus (E08.00-E13.9), arteriosclerosis of native arteries (I70.201-I70.92), phlebitis and thrombophlebitis of lower extremities (I80.00-I80.9), abscess, cellulitis, and lymphangitis of the toe and foot.

Covered diagnosis: Remember, if there is no covered diagnosis, you will not receive coverage for routine nail care. Apart from systemic conditions that necessitate routine nail care, you will also receive coverage for nail care when the patient suffers from mycosis of the nails and is experiencing pain, possibility of secondary infections, or reduced ambulation due to the affected nail(s).

Documentation requirements: When the physician provides nail care to a patient with a systemic condition, the physician must document class findings in the record to support the service’s medical necessity. Class findings fall under the following categories:

• Class A findings — “non-traumatic amputation” of the foot or integral part of the foot skeleton.
• Class B findings — absent posterior tibial or dorsalis pedis pulse or three of the following: hair growth (decrease or absence), nail changes (thickening), pigmentary changes (discoloration), skin texture (thin, shiny), and skin color (rubor or redness).
• Class C findings — edema, claudication, temperature changes, abnormal spontaneous sensations in the feet (paresthesia), and burning.

Modifiers: You must use the Q7 modifier to indicate one Class A finding, the Q8 modifier to indicate two Class B findings, or the Q9 modifier to indicate one Class B finding and two Class C findings.