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Podiatry Billing – General Medicare Coverage Guidelines
By: Cal LaGroue
In this article, we’ll discuss various common disorders within the field of podiatry, But more importantly, we’ll discuss when Medicare covers professional treatment for these disorders. A large percentage of foot care is classified as routine, and thus not covered by insurance. The reasoning being that ‘routine care’ does not require the skills of a medical professional. So, in order to avoid podiatry billing nightmares, it’s important for providers and patients to know the distinguishing factors that define eligibility for podiatry Medicare coverage.
Common Issues that are Generally NOT Covered
‘Routine Foot Care’ (as defined by Medicare)
Corns and callus cutting or removal
General nail maintenance (trimming, cutting, clipping, or debriding), and
Other hygienic and preventive maintenance, such as:
cleaning and soaking of the feet,
the use of skin creams to maintain skin tone of either ambulatory or bedfast patients,
any other service performed in the absence of localized illness, injury, or symptoms involving the foot.
Defined as a condition in which one or more arches of a foot have, in layman’s terms, flattened out. Services and devices used to treat this condition (including supportive devices and prescriptions) are not covered.
General Supportive Devices
Orthopedic shoes and other supportive devices for the feet are not generally covered,
However, Medicare does cover shoes if they are an integral part of some sort of covered treatment, such as a leg brace. There is also a narrow exception that allows coverage of special shoes (and inserts) for some patients with diabetes.
Exceptions: When Common Issues May be Covered
The presence of a systemic condition may require scrupulous foot care by a professional. In such instances, ‘routine foot care’ that would typically not be covered under Medicare’s podiatry billing rules, may in fact be covered. Such instances include metabolic and neurological conditions, as well as peripheral vascular disease.
In other words, when certain conditions result in severe circulatory embarrassment or areas of diminished sensation in the individual’s legs or feet, certain routine foot care procedures may pose a hazard if not performed by a professional. Thus, coverage extends to routine care (such as: cutting/removing corns and calluses; trimming, cutting, clipping, or debriding nails)
Incomplete List of Conditions that Allow ‘Routine Foot Care’ to be Covered:
Diabetes mellitus *
Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive
Buerger’s disease (thromboangiitis obliterans)
Chronic thrombophlebitis *
Peripheral neuropathies involving the feet
Associated with malnutrition and vitamin deficiency *
Malnutrition (general, pellagra)
Malabsorption (celiac disease, tropical sprue)
Associated with carcinoma *
Associated with diabetes mellitus *
Associated with drugs and toxins *
Associated with multiple sclerosis *
Associated with uremia (chronic renal disease) * o Associated with traumatic injury
Associated with leprosy or neurosyphilis
Associated with hereditary disorders
Hereditary sensory radicular neuropathy
Angiokeratoma corporis diffusum (Fabry’s)
(Note: If a condition above has an asterisk, the patient must be under the active care of a doctor of medicine or osteopathy (who documents the condition) for coverage to be extended)
Other Covered Conditions
The treatment of warts (including plantar warts) on the foot is covered to the same extent as warts located elsewhere on the body.
Treatment of mycotic nails may be covered, even in the absence of a systemic condition
The treatment of mycotic nails for an ambulatory patient is covered only when the physician attending the patient’s mycotic condition documents that (1) there is clinical evidence of mycosis of the toenail, and (2) the patient has marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.
The treatment of mycotic nails for a non ambulatory patient is covered only when the physician attending the patient’s mycotic condition documents that (1) there is clinical evidence of mycosis of the toenail, and (2) the patient suffers from pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.
Specific Podiatry Billing Guidelines for Complicating Conditions
When submitting claims for Medicare patients with complicating conditions, the name of the M.D. or D.O. who diagnosed the condition must be included in the claim, along with the approximate date when the patient last saw that physician.
When a systemic condition requires routine care to be conducted by a professional, carefully document any convincing evidence, showing that non-professional performance of a service would have been hazardous for the beneficiary because of the underlying systemic disease. Simply stating that the patient has a complicating condition, does not intrinsically guarantee Podiatry billing coverage.
The exclusion of foot care is determined by the nature of the service and not according to who provides the service. In other words, make sure that submitted clinical documentation (and Medicare guidelines) support any routine care provided, if coverage is meant to be extended
Sometimes coverage is extended to incidental non-covered services that are performed as a necessary and integral part of a covered procedure. An example would be: maintenance, like trimming, that is required to create better access for a covered procedure. However, such an instance would be considered part of the covered service and thus, could not be submitted as a separate claim.