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Practice Management Alert

Reader Question:

Trim Away Nail and Foot Medicare Denials

Published on Tue Apr 01, 2003

Question: We've recently received an onslaught of Medicare denials for foot and nail services. Why is this, and how can we clean up our claims?

Kentucky Subscriber

Answer: Your increase in denials may be the consequence of an Office of Inspector General (OIG) investigation. The federal watchdog recently studied the appropriateness of Medicare nail debridements, the single largest paid podiatric service, and found some reason for concern. About one in four claims didn't have sufficient documentation to justify the need for nail debridement, and half of these payments included other related inappropriate payments.

In light of this crackdown, and your recent denials, review these Medicare requirements for foot and nail service payment:

  • Do not bill for routine foot care, because Medicare won't pay. Care includes the cutting or removal of corns and calluses; the trimming, cutting, clipping or debriding of nails; other hygienic and preventive maintenance care such as cleaning and soaking the foot, 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.
  • Do bill for the exceptions to the foot-care exclusions. They include services performed as a necessary integral part of otherwise covered services such as diagnosis and treatment of ulcers, wounds, infections and fracture; the presence of a systemic condition such as metabolic, neurologic or peripheral vascular disease that may require scrupulous foot care by a professional; diabetic patients with certain diagnostic conditions; treatment of warts, including plantar warts (conditionally); treatment of mycotic nails for an ambulatory patient when the physician attending a patient's mycotic condition documents specified details in the medical record.

    Note the main HCPCS/CPT codes for billing foot and nail-care services:

  • 11719 Trimming of nondystrophic nails, any number
  • 11720 Debridement of nail(s) by any method(s); one to five
  • 11721 ... six or more
  • 11730* Avulsion of nail plate, partial or complete, simple; single
  • +11732 each additional nail plate (list separately in addition to code for primary procedure).

    Review the following CMS memorandums for claim and billing instruction for peripheral neuropathy: AB-02-096 (July 17, 2002) and AB-02-109 (July 31, 2002). The first one revises previous April 2002 memorandum AB-02-042 by clarifying the definition of the services that fall under these two HCPCS codes

  • G0245 Initial physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS)
  • G0246 Follow-up physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) ...

    The second one clarifies the claims changes required starting Jan, 1, 2003, with regards to that April memorandum.

  • Always check your Medicare carrier's local medical review policy.

    You Be the Expert and Reader Questions were reviewed by Catherine Brink CMM, CPC, president of Healthcare Resource Management Inc. in Spring Lake, N.J.

     

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