I am new to podiatry coding. Can someone tell me when it is appropriate to bill office visits 99xxx vs the G0245-47? If I use the G codes, would I use the 11055, 110721... codes. What documantation is needed to qualify the visit as an exam vs just the nails and or callus care. We recently picked up this podiatry client and I'm going to have to re-instruct the providers if they are billing these wrong.
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Pam Warren
True Blue
Overall, if Medicare has a HCPCS code for that service, don't use an E&M code. Also, if scheduled for foot care, don't also bill an E&M unless there's a change in care plan, or a new problem. The RAC, OIG and the MACs are all over this kind of service, because it's so complicated and so often billed (and paid) inappropriately.
I appreciate this information. I have read these articles but I am still unsure. We have people that come in frequently to get the nails and calluses done, usually every 10 weeks or so. I know the eval codes can only be used every 6 months. I haven't actually seen anything stating the frequency of the routine foot care. I have been seeing a lot of visits where they perform nail debridement and callus trimming then bill 99213. I feel like that is not corrrect but I don't know if I should just add 11721 an 11055 or remove the 99213 and just bill the other 2 or should I use the G0247?
podcoder70
Expert
Hello! Podiatry coding is very detailed and MAC specific. If a new patient comes in to establish and have foot care, you can bill the e&m along with the treatment. If the patient comes in just for callus or nail treatment and it is not a new issue, an e&m is not appropriate unless the patient also has a complaint that is unrelated to the callus and nails and is being treated that visit. As a rule, Medicare does not cover "diabetic foot exams" as they do not cover "screening" visits.
Feel free to reach out to me toniasilva856@gmail.com I have 20+ years experience in podiatry.
Feel free to reach out to me toniasilva856@gmail.com I have 20+ years experience in podiatry.
podcoder70
Expert
We call that "routine foot care" and no, an e&m should not be billed every time they come in for nails and calluses.
Would a 99212 be appropriate if the patient hasn't been seen for foot care with our clinic since 7/28/2020? Pt had callus trim and nail debridement at that visit back in 2020 and is coming back now almost a year later for the same. Dr has chosen codes: 99212,11055,11721
podcoder70
Expert
There is a lot of debate on that, sorry for the delayed response. It's all about documentation. What is the doctor "evaluating and treating"? An "annual exam" is not payable for podiatry. The patient needs to have a complaint that is being treated and needs to have a "work up". Perhaps there was a new callus from last visit, or increased numbness that is discussed, or new fungal nails. Again, documentation is the key to support the E&M. Feel free to reach out to me, Wendy.
lipstick
Contributor
there have to be certain ICD-10 codes to support 11055-11057 and 11720/21. Medicare will not pay for these services if they are performed more frequently than 9 weeks. The every 6 months is the Date Last Seen for certain systemic chronic conditions. It is complicated. To bill the e/m, it would need to be separate form the foot care services. There might be other reasons why the patient is being seen. I think there are some unanswered questions
napahny@aol.com
Networker
Hello dear, I would like to ask for your help in podiatry billing, may I email you few questions?
Thank you in advance!
Mariam
Napahny@aol.com
podcoder70
Expert
I emailed you Mariam.
rose731red
New
I am new to podiatry coding as well and also pretty confused about most of the codes and guidelines. I am pretty new to coding in general as well and get confused with even simple things like, if I should query the physician for not putting a procedure note when it already states what they did just note under a procedure note heading? Would you be open to answering some very basic random questions about podiatry?
I have gathered lots of experience billing routine foot care to Medicare. I would be happy to answer questions.
Bernadette10
Guru
Is it correct to code a diagnosis of diabetes from the past medical history with the patient currently on metformin in order to have a covered diagnosis for G0127 routine trimming of dystrophic nails for Medicare? This is a podiatry clinic, and the podiatrist doesn't list diabetes as a diagnosis, but is it considered related?
Patient comes in for diabetic nail trimming.
Review of Systems:
HENT - Negative
Musc - Negative
Neurological - Negative
Past Medical History: Diabetes, seasonal allergies.
Current medications: Metformin, loratadine.
Exam:
Distal pulses palpable left 1, right 1. Pedal pulses palpable left 1, right 1.
Pedal hair present bilaterally.
No edema, ecchymosis or erythema.
Skin temperature warm to cool proximal to distal bilaterally. No open wounds.
No varicosities/spider veins.
Diagnosis: Onychomycosis bilaterally.
Nails were noted to be thickened, discolored, brittle with subungual debris. Nails were trimmed bilaterally using 5 inch nail nippers without any bleeding noted. Patient tolerated well.
Patient comes in for diabetic nail trimming.
Review of Systems:
HENT - Negative
Musc - Negative
Neurological - Negative
Past Medical History: Diabetes, seasonal allergies.
Current medications: Metformin, loratadine.
Exam:
Distal pulses palpable left 1, right 1. Pedal pulses palpable left 1, right 1.
Pedal hair present bilaterally.
No edema, ecchymosis or erythema.
Skin temperature warm to cool proximal to distal bilaterally. No open wounds.
No varicosities/spider veins.
Diagnosis: Onychomycosis bilaterally.
Nails were noted to be thickened, discolored, brittle with subungual debris. Nails were trimmed bilaterally using 5 inch nail nippers without any bleeding noted. Patient tolerated well.
We code the diabetes unless it is specified as uncomplicated since that is not a covered dx on the LCD. Usually they have neuropathy or vascular disorders which makes foot care difficult and risky if not done properly. I tell my providers that the diabetes needs to be mentioned in the Hx or exam in order to support coding. Type 2 also requires that use of insulin or hypoglycemic drugs be coded also. Your patient has B35.1 so (based on Noridian's LCD) they would be required to have a covered secondary dx such as pain, neuropathy, diabetes, or vascular issues. you would also need to review the guidelines for Q 7, 8, or 9 if they have vascular issues.
Bernadette10
Guru
Thank you! Someone showed me an older AAPC article that's also helpful for this: https://www.aapc.com/blog/23995-warning-trimming-toe-nails-can-be-hazardous/
What is medically necessary routine foot care and what are the exceptions to Medicare exclusions?
Medicare requires the presence of a systemic condition for possible coverage. Foot care otherwise considered routine may be covered when the systemic conditions result in severe circulatory compromise and diminished sensation in the individual’s legs or feet. In these circumstances, routine foot care (for example, trimming of corn and calluses, debridement of nails) may pose a hazard when provided by a non-professional. Completely document convincing evidence to show non-professional services are hazardous for the patient due to underlying systemic disease. Merely documenting a patient has a complicating condition, such as diabetes, does not constitute coverage as it doesn’t show the severity of the condition. Medicare provides guidance on systemic conditions or complicating conditions that may justify routine foot care coverage.
What is medically necessary routine foot care and what are the exceptions to Medicare exclusions?
Medicare requires the presence of a systemic condition for possible coverage. Foot care otherwise considered routine may be covered when the systemic conditions result in severe circulatory compromise and diminished sensation in the individual’s legs or feet. In these circumstances, routine foot care (for example, trimming of corn and calluses, debridement of nails) may pose a hazard when provided by a non-professional. Completely document convincing evidence to show non-professional services are hazardous for the patient due to underlying systemic disease. Merely documenting a patient has a complicating condition, such as diabetes, does not constitute coverage as it doesn’t show the severity of the condition. Medicare provides guidance on systemic conditions or complicating conditions that may justify routine foot care coverage.
Bernadette10
Guru
I found a newer reference. The Novitas site https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144510 lists uncomplicated diabetes as being covered if the patient is under the care of a physician for it, but apparently there also needs to be documentation of this.
Article - Billing and Coding: Routine Foot Care (A57957) (cms.gov)
Below is a summary of the expected coding and billing to be used when billing for routine foot care that meets the criteria as established in the CMS Internet Only Manual, Benefit Policy Manual, Pub 100-02 Chapter 15, Section 290 linked in the Associated Documents section below.
Please note the clinical documentation must clearly show that the patient’s condition warrants a provider rendering these services in accordance with the above instruction and failure to provide such professional services would be hazardous to the beneficiary due to their underlying medical condition(s). Failure to properly document the reasoning for the care rendered may result in denial of the claim.
In addition, the beneficiary may have complicating diagnosis(es) that require them to be under the care of a primary physician for the disease that is causing the beneficiary to seek provider based routine foot care. For the asterisked conditions, the name of the primary physician (must be a D.O. or M.D.) who made the diagnosis, and the approximate date of the last visit should be included in the record and entered on the appropriate claim forms or electronic equivalent when billing Medicare per the Benefit Policy Manual noted above. Please refer to the CMS website for instructions for billing Part A and Part B claims. There is also information on Noridian’s website for JF Part B claims.
Routine foot care services are not restricted to podiatrists. These services may be used by any certified physician or non-physician (NPP) specialty, in keeping with State licensure, if applicable, to provide proper care in either a Part A facility or physician’s office.
Article - Billing and Coding: Routine Foot Care (A57957) (cms.gov)
Below is a summary of the expected coding and billing to be used when billing for routine foot care that meets the criteria as established in the CMS Internet Only Manual, Benefit Policy Manual, Pub 100-02 Chapter 15, Section 290 linked in the Associated Documents section below.
Please note the clinical documentation must clearly show that the patient’s condition warrants a provider rendering these services in accordance with the above instruction and failure to provide such professional services would be hazardous to the beneficiary due to their underlying medical condition(s). Failure to properly document the reasoning for the care rendered may result in denial of the claim.
In addition, the beneficiary may have complicating diagnosis(es) that require them to be under the care of a primary physician for the disease that is causing the beneficiary to seek provider based routine foot care. For the asterisked conditions, the name of the primary physician (must be a D.O. or M.D.) who made the diagnosis, and the approximate date of the last visit should be included in the record and entered on the appropriate claim forms or electronic equivalent when billing Medicare per the Benefit Policy Manual noted above. Please refer to the CMS website for instructions for billing Part A and Part B claims. There is also information on Noridian’s website for JF Part B claims.
Routine foot care services are not restricted to podiatrists. These services may be used by any certified physician or non-physician (NPP) specialty, in keeping with State licensure, if applicable, to provide proper care in either a Part A facility or physician’s office.
podcoder70
Expert
E11.9 is a covered diagnosis for shoes and inserts. However, the certifying statement must have one or more of the following conditions to qualify: 1. History of partial or complete amputation of foot, 2. History of previous foot ulceration, 3. History of pre-ulcerative callus, 4. peripheral neuropathy with evidence of callus formation, 5. foot deformity, 6. poor circulation.
Most patients have #5...some type of deformity, such as hammertoe, bunion, etc.
Most patients have #5...some type of deformity, such as hammertoe, bunion, etc.