Routine foot care is excluded from coverage by the Medicare program, meaning they will not pay for these services; however, exceptions to this exclusion exist. They include:
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- Routine foot care that is necessary and an integral part of an otherwise covered service;
- Treatment of warts on foot;
- The presence of systemic conditions, such as metabolic, neurologic, or peripheral vascular disease;
- Mycotic nails, under specific circumstances.
For this post we are going to focus on number 3, the exception that is made when a patient has a systemic condition. Per the Medicare Benefit Policy Manual (“MBPM”), Chapter 15, Section 290, the presence of a systemic condition “…may require scrupulous foot care by a professional that in the absence of such condition(s) would be considered routine (and, therefore, excluded from coverage).” This is due to the fact that certain conditions could pose a serious threat to a patient who tries to care for their own feet.
The MBPM goes on to list systemic conditions that might justify coverage for routine foot care, including diabetes mellitus, arteriosclerosis obliterans and peripheral neuropathies involving the feet. The list is not intended to be comprehensive but is a good place to start when determining whether a condition will satisfy coverage criteria.
Certain systemic conditions included on the list contain an asterisk (*). When an asterisk is present, the patient must be under the active care of a Doctor of Medicine or Osteopathy who manages the condition and must have been seen within the past 6 months for the routine procedure to be covered. Some of the Medicare Administrative Contractors (“MAC”) also allow management of a patient’s systemic condition by a Non-Physician Practitioner (“NPP”). The name and NPI of the provider managing the systemic condition as well as the date the patient was last seen must be documented on the claim form in blocks 17 and 17b (name and NPI), and block 19 (date last seen). This information is often corroborated with documentation in the visit note.
Medicare allows for a presumption of coverage to be made when documentation supports certain physical/clinical findings (referred to as class findings) that are indicative of severe peripheral involvement and therefore pose a threat to the patient. The class findings are:
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 to meet one class B finding); 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 following combination of class findings must be documented by the provider rendering the routine foot care for the presumption of coverage to be applied:
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- A Class A finding;
- Two of the Class B findings; or
- One Class B and two Class C findings.
To indicate the presumption of coverage has been satisfied by documentation, a class findings modifier will be appended to the appropriate routine foot care procedure code(s) (11055-11057, 11719-11721 or G0127). -Q7 when a class A finding is documented, -Q8 when two of the class B findings are documented or -Q9 when one class B finding, and two class C findings are documented. When coverage is based on the presence of a systemic condition, documentation must support use of one of these modifiers. This information must be documented at each and every visit where routine foot care services are rendered. Routine foot care procedures can only be performed once in 60 days.
To sum up foot care with systemic condition coverage: the patient must be diagnosed with a qualifying systemic condition (with active care requirement information documented on the claim, when applicable), documentation must support use of one of the class findings modifiers, and the procedures can only be performed once in a 60- day period.
Be sure to check private payor policies and your specific MAC Local Coverage Determinations and Articles as requirements may vary.
If you are struggling with foot care coverage, Pinnacle can help you stand on your own two feet!
