Article - Billing and Coding: Foot Care (A56232)

CMS National Coverage PolicyCMS Publication, IOM 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 290  Foot CareCMS Publication IOM 100-03 Medicare National Coverage Determinations(NCD) Manual, Chapter 1, Part 1, Coverage Determinations, Section 70.2.1 Services Provided for the Diagnosis and Treatment of Diabetic Sensory Neuropathy with Loss of Protective Sensation (aka Diabetic Peripheral Neuropathy)42 CFR  411.15 - Particular services excluded from coverage (l) Foot careArticle TextRoutine foot care is usually performed by the beneficiary himself or herself, or by a caregiver.Generally, routine foot care is excluded from coverage. Services that normally are considered routine and not covered by Medicare can be found in Publication Number 100-02 Medicare Benefit Policy Manual, Chapter 15 Covered Medical and Other Health Services, Section 290.2 Routine Foot Care. WPS GHA would also include the shaving, paring, cutting, or removal of keratoma, tyloma, and heloma as routine foot care excluded from coverage.IndicationsRoutine foot care services are subject to national regulations, which provides definitions, indications, and limitations for Medicare payment of routine foot care services.Medicare Benefit Policy Manual (Pub. 100-02), Chapter 15, Section 290 describes exceptions to routine foot care exclusions.WPS GHA includes mycotic nails with the following exceptions to routine foot care exclusions:In the presence of systemic conditions such as metabolic, neurologic, and peripheral vascular diseases.In the absence of systemic conditions:Ambulatory patient must have marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of infected toenail plate.Non-ambulatory patient suffers from pain or secondary infection resulting from the thickening and dystrophy of infected toenail plate.Systemic ConditionsFoot care services are covered in the presence of a systemic condition. Refer to the Medicare Benefit Policy Publication 100-02, Chapter 15, Section 290.4 D Systemic Conditions That Might Justify Coverage for a list of systemic conditions. For diagnosis codes designated by an asterisk (*), it is required the patient be under the active care of Doctor of Osteopathic Medicine (D.O.) or Doctor of Medicine (M.D.) The active care requirement would be considered met if the claim indicates that the patient has seen an M.D. or D.O. for treatment and/or evaluation of the complicating disease process during the 6-month period prior to the service. A list of diagnosis codes can be found in Group 1 Paragraph under ICD-10 Codes that Support Medical Necessity.Presumption of CoverageRefer to the Medicare Benefit Policy Publication 100-02, Chapter 15, Section 290.4 D. for a list of conditions with a presumption of coverage for routine services.In addition to a valid billing modifier, these services must include a systemic condition diagnosis listed in IOM 100-02, Chapter 15, Section 290 and in Group 1 of the diagnosis codes. All claims for routine foot care based on the presence of a systemic condition must have a billing modifier of Q7, Q8, or Q9 to be considered for payment.Mycotic NailsMycotic nail debridement may be a covered service:In the presence of a systemic disease with the class findings and appropriate Q modifier.In the absence of systemic disease if the patient has mycotic nails and marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of infected toenail plate.In the absence of systemic disease when a non-ambulatory patient has mycotic nails and suffers from pain or secondary infection resulting from the thickening and dystrophy of infected toenail plate.For services without systemic disease and class findings, the diagnosis in Group 2 and Group 3 of the diagnosis codes below must be documented in the medical record and submitted on the claim.The nail debridement procedure codes are considered non-covered routine foot care when these services do not meet the guidelines outlined above for mycotic nail services.LimitationsCovered exceptions to routine foot care services are considered medically necessary once (1) in 60 days. More frequent services will be denied as not reasonable and necessary.The exclusion of foot care is determined by the nature of the service, regardless of the clinician who performs the service.Medicare allows payment for routine foot care only if the conditions under indications are met. These conditions describe the systemic diseases and their peripheral complications that increase the danger for infection and injury if a non-professional provides these services.Services not meeting the criteria in this statement of national coverage will be denied as statutory non-covered services. For diagnosis codes designated by an asterisk (*), we will require the date the patient was last seen (DPLS) and the NPI of the Doctor of Medicine or Doctor of Osteopathic Medicine actively managing the patients systemic condition.Nail debridement procedures are considered non-covered routine foot care when these services do not meet the guidelines outlined above for mycotic nail services or are not based on the presence of a systemic condition. If the nail debridement procedures are performed in the absence of mycotic nails and as part of foot care, they must meet the same criteria as all other routine foot care services to be considered for payment.Foot care services that do not require a professional would be considered routine and not a Medicare benefit. Professional in this situation is defined as an M.D., D.O., D.P.M., Nurse Practitioner, Clinical Nurse Specialist, or Physician Assistant.A Registered Nurse that holds foot care certification (CFCN) may perform covered foot care services when all the following requirements are met:Services are performed under direct supervision of a physician or other practitionerAll requirements of the incident to provision are met per the CMS Medicare Benefit Policy ManualProof of accredited Foot Care Nurse certification must be included in the documentationAll other coverage provisions outlined in this Billing and Coding Article are metLoss of protective sensation (LOPS) is not the subject of this coverage article. Please refer to CMS Publication, 100-03, Medicare National Coverage Determination Manual 70.2.1 Services Provided for the Diagnosis and Treatment of Diabetic Sensory Neuropathy with Loss of Protective Sensation (aka Diabetic Peripheral Neuropathy).General InformationDocumentation RequirementsDocumentation in the medical record must support the services as billed, meet the criteria in the indications section above, and be available upon request.Utilization GuidelinesReview Benefit Policy Manual (Pub. 100-02), Chapter 15, Section 290 G. Application of Foot Care Exclusions to Physicians Services for an explanation of situations that would require medical record review.Services performed for a localized condition that created a painful condition/complication that could not be otherwise managed by the patient and would place the patient at risk if not performed by a professional, would require medical record review.Services for debridement of more than five nails in a single day may be subject to medical review.