(Medicare Benefit Policy Manual)

Review of the individuals functional ability and level of safety:  At a minimum, includes assessment of the following topics:   a.  Hearing impairment,   b.  Ability to successfully perform activities of daily living,   c. Fall risk, and,   d. Home safety.   Subsequent AWV providing PPPS:  The provision of the following services to an eligible beneficiary by a health professional that include, and take into account the results of an updated health risk assessment, as those terms are defined in this section:   a.  Review (and administration if needed) of an updated health risk assessment (as defined in this section).   b.  An update of the individuals medical/family history.  c.  An update of the list of current providers and suppliers that are regularly involved in providing medical care to the individual, as that list was developed for the first AWV providing PPPS or the previous subsequent AWV providing PPPS.   d.  Measurement of an individuals weight (or waist circumference), BP, and other routine measurements as deemed appropriate, based on the individuals medical/family history.   e.  Detection of any cognitive impairment that the individual may have as defined in this section.   f.  An update to the following:   (1)  The written screening schedule for the individual as that schedule is defined in this section, that was developed at the first AWV providing PPPS, and,  (2)  The list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are under way for the individual, as that list was developed at the first AWV providing PPPS or the previous subsequent AWV providing PPPS.   g.  Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs as that advice and related services are defined for the first AWV providing PPPS.   h.  Any other element determined appropriate by the Secretary through the NCD process.   See Pub. 100- 04, Medicare Claims Processing Manual, chapter 18, section 140, for detailed claims processing and billing instructions.   280.5.1  Advance Care Planning (ACP) Furnished as an Optional Element with an Annual Wellness Visit (AWV) Upon Agreement with the Patient  (Rev. 216 Issued: 12- 22-15, Effective: 01 -01-16, Implementation: 01- 04-16)  Beginning in CY 2016, CMS will treat an AWV and voluntary ACP that are furnished on the same day and by the same provider as a preventive service.  Voluntary ACP services, upon agreement with the patient, will be an optional element of the AWV.  (See section 1861(hhh)(2)(G) of the Act.)  When ACP services are furnished as a part of an AWV, according to sections 1833(a)(1) and 1833(b)(10) of the Act, the coinsurance and deductible are waived.   Voluntary advance care planning means the face- to-face service between a physician (or other qualified health care professional) and the patient discussing advance directives, with or without completing relevant legal forms.  An advance directive is a document appointing an agent and/or recording the wishes of a patient pertaining to his/her medical treatment at a future time should he/she lack decisional capacity at that time.   See Pub. 100-04, Medicare Claims Processing Manual, chapter 18, section 140.8 for claims processing and billing instructions.  290 - Foot Care  (Rev. 1, 10-01-03) A3-3158, B3-2323, HO-260.9, B3-4120.1  A.  Treatment of Subluxation of Foot  Subluxations of the foot are defined as partial dislocations or displacements of joint surfaces, tendons ligaments, or muscles of the foot. Surgical or nonsurgical treatments undertaken for the sole purpose of correcting a subluxated structure in the foot as an isolated entity are not covered.   However, medical or surgical treatment of subluxation of the ankle joint (talo- crural joint) is covered. In addition, reasonable and necessary medical or surgical services, diagnosis, or treatment for medical conditions that have resulted from or are assoc iated with partial displacement of structures is covered. For example, if a patient has osteoarthritis that has resulted in a partial displacement of joints in the foot, and the primary treatment is for the osteoarthritis, coverage is provided.  B.  Exclusions from Coverage  The following foot care services are generally excluded from coverage under both Part A and Part B. (See 290.F  and 290.G for instructions on applying foot care exclusions.)  1.  Treatment of Flat Foot  The term flat foot is defined as a condition in which one or more arches of the foot have flattened out. Services or devices directed toward the care or correction of such conditions, including the prescription of supportive devices, are not covered.  2.  Routine Foot Care  Except as provided above, routine foot care is excluded from coverage. Services that normally are considered routine and not covered by Medicare include the following:   The cutting or removal of corns and calluses;   The trimming, cutting, clipping, or debriding of nails; and   Other hygienic and preventive maintenance care, such as cleaning and soaking the feet, the 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.  3.  Supportive Devices for Feet   Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics.  C.  Exceptions to Routine Foot Care Exclusion  1.  Necessary and Integral Part of Otherwise Covered Services   In certain circumstances, services ordinarily considered to be routine may be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of ulcers, wounds, or infections.  2.  Treatment of Warts on Foot  The treatment of warts (including plantar warts) on the foot is covered to the same extent as services provided for the treatment of warts located elsewhere on the body.   3.  Presence of Systemic Condition  The presence of a systemic condition such as metabolic, neurologic, or peripheral vascular disease may require scrupulous foot care by a professional that in the absence of such condition(s) would be considered routine (and, therefore, excluded from covera ge). Accordingly, foot care that would otherwise be considered routine may be covered when systemic condition(s) result in severe circulatory embarrassment or areas of diminished sensation in the individuals legs or feet. (See subsection A.)  In these instances, certain foot care procedures that otherwise are considered routine (e.g., cutting or removing corns and calluses, or trimming, cutting, clipping, or debriding nails) may pose a hazard when performed by a nonprofessional person on patients with such systemic conditions. (See 290.G for procedural instructions.)  4.  Mycotic Nails   In the absence of a systemic condition, treatment of mycotic nails may be covered.   The treatment of mycotic nails for an ambulatory patient is covered only when the physician attending the patients 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 nonambulatory patient is covered only when the physician attending the patients 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.  For the purpose of these requirements, documentation means any written information that is required by the A/B MAC (B) in order for services to be covered. Thus, the information submitted with claims must be substantiated by information found in the patien ts medical record. Any information, including that contained in a form letter, used for documentation purposes is subject to A/B MAC (B) verification in order to ensure that the information adequately justifies coverage of the treatment of mycotic nails.   D.  Systemic Conditions That Might Justify Coverage   Although not intended as a comprehensive list, the following metabolic, neurologic, and peripheral vascular diseases (with synonyms in parentheses) most commonly represent the underlying conditions that might justify coverage for routine foot care.   Diabetes mellitus  *  Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis)  Buergers disease (thromboangiitis obliterans)  Chronic thrombophlebitis  * Peripheral neuropathies involving the feet -   Associated with malnutrition and vitamin deficiency *   Malnutrition (general, pellagra)   Alcoholism   Malabsorption (celiac disease, tropical sprue)   Pernicious anemia  Associated with carcinoma  *  Associated with diabetes mellitus  *  Associated with drugs and toxins  * Associated with multiple sclerosis  *  Associated with uremia (chronic renal disease)  *  Associated with traumatic injury  Associated with leprosy or neurosyphilis  Associated with hereditary disorders   Hereditary sensory radicular neuropathy  Angiokeratoma corporis diffusum (Fabrys)   Amyloid neuropathy  When the patients condition is one of those designated by an asterisk (*), routine procedures are covered only if the patient is under the active care of a doctor of medicine or osteopathy who documents the condition.  E.  Supportive Devices for Feet   Orthopedic shoes and other supportive devices for the feet generally are not covered.  However, this exclusion does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the cost of the brace.  Also, this exclusion does not apply to therapeut ic shoes furnished to diabetics.   F.  Presumption of Coverage   In evaluating whether the routine services can be reimbursed, a presumption of coverage may be made where the evidence available discloses certain physical and/or clinical findings consistent with the diagnosis and indicative of severe peripheral involveme nt.  For purposes of applying this presumption the following findings are pertinent:   Class A Findings   Nontraumatic amputation of foot or integral skeletal portion thereof.   Class B Findings   Absent posterior tibial pulse;  Advanced trophic changes as: hair growth (decrease or absence) nail changes (thickening) pigmentary changes (discoloration) skin texture (thin, shiny) skin color (rubor or redness) (Three required); and  Absent dorsalis pedis pulse.  Class C Findings   Claudication;  Temperature changes (e.g., cold feet);  Edema;  Paresthesias (abnormal spontaneous sensations in the feet); and  Burning.  The presumption of coverage may be applied when the physician rendering the routine foot care has identified:   1.  A Class A finding;  2.  Two of the Class B findings; or  3.  One Class B and two Class C findings.   Cases evidencing findings falling short of these alternatives may involve podiatric treatment that may constitute covered care and should be reviewed by the intermediarys medical staff and developed as necessary.   For purposes of applying the coverage presumption where the routine services have been rendered by a podiatrist, the A/B MAC (B) may deem the active care requirement met if the claim or other evidence available discloses that the patient has seen an M.D. o r D.O. for treatment and/or evaluation of the complicating disease process during the 6- month period prior to the rendition of the routine -type services.  The A/B MAC (A) may also accept the podiatrists statement that the diagnosing and treating M.D. or D .O. also concurs with the podiatrists findings as to the severity of the peripheral involvement indicated.   Services ordinarily considered routine might also be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of diabetic ulcers, wounds, and infections.   G.  Application of Foot Care Exclusions to Physicians Services   The exclusion of foot care is determined by the nature of the service. Thus, payment for an excluded service should be denied whether performed by a podiatrist, osteopath, or a doctor of medicine, and without regard to the difficulty or complexity of the procedure.   When an itemized bill shows both covered services and noncovered services not integrally related to the covered service, the portion of charges attributable to the noncovered services should be denied.  (For example, if an itemized bill shows surgery for an ingrown toenail and also removal of calluses not necessary for the performance of toe surgery, any additional charge attributable to removal of the calluses should be denied.)   In reviewing claims involving foot care, the A/B MAC (B) should be alert to the following exceptional situations: