Submitting Medicare Part B

Claims for Foot Care Services

Objectives
Overview of coverage and policy
guidelines for foot care services
Understanding of claims filing guidelines
Identify key Medicare claims related data
for podiatry services
Utilizing provider self-service tools

Coverage and Billing Guidelines

Medicares Definition of

Routine Foot Care

Cutting or removal of corns or calluses

Trimming, cutting, clipping, or debriding of
nails
Hygienic and preventive maintenance care
such as:
Cleaning and soaking the feet
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

Routine Foot Care Coverage

CMS has national-level guidelines
governing routine foot care
Routine foot care is not a covered Medicare
benefit
Medicare assumes that the beneficiary or
caregiver will perform these services by
themselves
There are certain exceptions to this rule

Exceptions to Routine Foot Care

Exclusion
Necessary and Integral Part of Otherwise
Covered Services
Presence of Systemic Condition
Treatment of Warts on Foot
Mycotic Nails
Class Findings
Reference
http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf
Medicare Benefit Policy Manual Chapter 15 Covered Medical
and Other Health Services section 290 - Foot Care

Systemic Conditions
The most common diagnoses that can
represent the underlying conditions to
justify coverage as exceptions to routine
foot care exclusions are:
Peripheral vascular conditions and diabetes
*Diabetes mellitus
Arteriosclerosis obliterans
Buergers disease
*Chronic thrombophlebitis

Systemic Conditions Cont

Peripheral neuropathies involving feet
Associated with:

*malnutrition & vitamin deficiency

*carcinoma

*diabetes mellitus

*drug or toxins

*multiple sclerosis

*uremia (chronic renal disease)

traumatic injury
Leprosy & neurosyphilis
Hereditary disorders (Fabrys), amyloid
neuropathy)

Systemic Conditions Cont

For the starred (*) conditions, routine foot

care is covered only if the patient is under
the active care of a doctor of medicine or a
doctor of osteopathy who documents the
condition

Class Findings
To be considered for coverage, the
severity of one of the listed diagnoses
must document the clear evidence of
significant circulatory changes defined
as:
1 Class A finding
2 Class B findings
1 Class B and 2 Class C findings

Class A Findings
Non-tramatic
amputation of the
foot or integral
skeletal portion of
the foot
Non-tramatic is
something that was
planned, not done
by accident

Class B Findings
Absent posterior tibial pulse
Absent dorsalis pedis pulse
Minimum of three trophic changes:
Decrease or absence of hair growth
Nail thickening
Skin discoloration
Thin and shiny skin texture
Rubor or redness of skin

Class C Findings

Claudication
Temperature changes
Edema
Paresthesias
Burning

Modifiers for Class Findings

Q7 - One Class A finding
Q8 - Two Class B findings
Q9 - One Class B finding and one Class C
finding

Debridement of Mycotic Nails

Covers 11720, 11721, 87101, 87102, &
87220
Objectives of debriding mycotic nails:
Relief of pain
Treatment of infection - bacteria and fungal
Exposure of subungal conditions for purpose
of treatment and diagnosis.

Mycotic Nail Debridement

Ambulatory Patient
Clinical evidence of mycosis
Limitation of ambulation
Pain
Secondary infection

Mycotic Nail Debridement

Nonambulatory Patient
Clinical evidence of a mycotic nail
Pain
Secondary infection

Clinical Evidence of Mycosis

Nail hypertrophy
Lysis
Discoloration of the nail
Brittleness
Loosening of the nail plate

Payable Coding Combinations

On the same day:
11720 or 11721
11055, 11056, or
11057

On the same day:

11719 or G0127
11055, 11056, or
11057

On the same day:

G0127
11055, 11056, or
11057

On the same day:

11720
11719 or G0127

Documentation
Palmetto GBA does not require
providers to submit documentation with
claims for routine foot care services
Evidence that the patient was under the
care of a doctor of medicine or osteopathy
during the preceding 6 months is required
Submit the National Provider Identifier
Number (NPI) of this doctor and the date
(8-digits) of the last visit to this doctor must
be submitted in Item 19 of the CMS-1500
Claim form or the electronic equivalent

Documentation cont.
The patient's medical record must document the medical
necessity of services performed for each date of service
submitted on a claim, and documentation must be available
to Medicare on request. The medical record must document
and identify:
The physician treating the systemic condition
The approximate last date of treatment by the M.D. or
D.O
The systemic condition.
The size and exact location of each lesion treated
The clinical documentation of class findings for each
date of service

Frequency
Services performed for excessive
frequency are not medically necessary
Considered excessive if:
services are performed more frequently
than generally accepted by peers, and
reason for additional services is not
justified by documentation

Treatment of Flat Foot

Medicare does not
cover for the care or
correction of a flat
foot.

Subluxation of the Foot

Treatment not covered if sole purpose is
correcting subluxated structure
Surgical correction covered only if:
Integral part of a foot injury
Performed to improve function of the foot
Alleviates an induced or associated symptomatic
condition

UNNAs Boot
Procedure 29580 covered for DX:
4402.23

454.2

707.10 - 707.19

Claims for services exceeding generally

accepted practice, must be accompanied
with written documentation to support
service.

Supportive Devices For Feet

Supportive devices for feet
Not covered by the Part B Carrier

Prosthetic Shoes
Can be covered as a terminal device
Must be integral parts of a leg brace or
therapeutic shoes for diabetic patients
Submit claims to the Durable Medical
Equipment MAC

Cigna Government Services

P. O. Box 20010

Nashville, TN 37202

Specialty Resources
References:
CMS Internet Only Manuals
(www.cms.hhs.gov/manuals):
The Medicare Benefit Policy Manual (Pub.
100-02), Chapter 15, section 290.B.2:
definition of routine foot care
The Medicare Benefit Policy Manual (Pub.
100-02), Chapter 15, section 290.C.3:
exceptions to the routine foot care exclusion

Claims Filing Tips

Claim Filing Tips for Routine Foot

Care
Date last seen by the patients attending
physician
NPI of the attending physician
One unit per day
Covered diagnosis
Q7, Q8, or Q9 Modifiers are required
Rebundling/Mutually Exclusive policies
apply

CMS 1500 Items 17 & 19

XXXXXXXXXX

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Claims Filing Tips for

Debridement of Mycotic Nails

Date last seen by the attending

physician/podiatrist
NPI of the attending physician/podiatrist
Bill 11720 or 11721, not both
Diagnosis 110.1 plus:
110.4, 681.10, 681.11, or 729.5

No modifiers required
An E/M will deny without a -25 modifier

Payable Coding Combinations

On the same day:
11720 or 11721
11055, 11056, or
11057

On the same day:

11719 or G0127
11055, 11056, or
11057

On the same day:

G0127
11055, 11056, or
11057

On the same day:

11720
11719 or G0127

Advance Beneficiary Notice (ABN)

Applicable to medical necessity denials
ABN must be in writing
Patient must be notified before service is
rendered
Blanket notices are not valid
Use GA modifier to indicate signed and
dated ABN on file

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ABN
New Form Effective March 1, 2009
Replaces the ABN-G and ABN-L
Replaces Notice of Notice of Exclusion from
Medicare Benefits (NEMB)
Has a mandatory field for cost estimates of
the items/services at issue
Includes a new beneficiary option,
Patient may choose to receive an item/service,
and pay for it out-of-pocket, rather than have a
claim submitted to Medicare

ABN
ABNs cannot be copied.
For replicable copies, visit CMSs Web site
at:
http://www.cms.hhs.gov/BNI/02_ABNGABNL
.asp
Also at: www.PalmettoGBA.com/bsc, Forms

Medicare Claims Related Data

Comprehensive Error Rate Testing
(CERT)

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CERT Reporting Periods

November 2007
Claims submitted in the 12 month period
ending March 31, 2007

May 2008
Claims submitted in the 12 month period
ending September 30 3007

Podiatry Error Rate

and Improper Payments
9.1%

74.3%

7.3%

9.4%

No Documentation
Insufficient
Documentation
Medically Unnecessary
Services
Incorrect Coding

November 2007

Podiatry Error Rate

and Improper Payments
8.9%
64.7%

18.4%

No Documentation
8.0%

Insufficient
Documentation
Medically Unnecessary
Services
Incorrect Coding

Mid Year 2008

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No Documentation Errors
Did not respond
Indicated that the beneficiary does not exist
Indicated that they submitted the claims for the
wrong date of service
Provider responded to inform violating HIPAA
Provider commented that they had gone out of
business

Insufficient Documentation Errors

Providers are confused about exactly what they
needed to submit to the CERT contractor
Portions of the medical record were not at the
same location therefore records were
incomplete
Providers failed to properly document the billed
service in the medical record
Providers stated that they misplaced the medical
record

Medically Unnecessary

Services Errors

Routine Foot Care Provided

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,
Other service performed in the absence of
localized illness, injury, or symptoms involving
the foot

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Incorrect Coding Errors

Incidental non-covered services that are performed as a
necessary and integral part of, and secondary to, a
covered procedure submitted as a E/M service
Missing the name of the M.D. or D.O. who diagnosed the
complicating condition must be submitted with the claim,
along with the approximate date that the beneficiary was
last seen by the indicated physician, when submitting
claims for services furnished to Medicare beneficiaries who
have complicating conditions
When an itemized bill shows both covered services and
noncovered services that are not integrally related to the covered
service, the portion of the charges that are attributable to the
noncovered services should not be submitted

Lets Work Together to Reduce the

CERT Error Rate?

Partnership to reduce errors

Documentation Problems
No Documentation response
Inadequate documentation response

Coding Errors

How to respond to the requests?

Where to Mail Records

Where should you mail CERT
records?
Records should be sent to the
following address:
CERT Documentation Contractor
9090 Junction Drive, Suite 9
Annapolis Junction, MD 20701
or

FAX to (240) 568-6222

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Provider Self-service Tools And

Technology

www.palmettogba.com/bsc

Modifier Lookup: Your Resource For

Correct Claim Submission

16

Global Surgery Denial Tool

Frequently Asked Questions:

New Content, New Look

Interactive Voice Response

(IVR) Unit

Call 1-866-238-9654
Payment Floor
Claim Information
Order a Duplicate
Remittance
Beneficiary Entitlement
Beneficiary Part B
Deductible

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Provider Outreach and

Education

Provider Outreach and

Education Department

Are you having a problem filing

your claims?
Do you have a new person in your
office?
Do you need a speaker for your
meeting?
If you would like an Ombudsman to
visit your office or to speak at a
meeting:
Call 866-238-9654 and choose
Option 8, or
Complete the Provider
Outreach and Education
Request Form located on the
Web site
http://www.palmettogba.com
/bsc

Palmetto GBA Publications

Physician Supplier Guide
Available on Palmetto GBA
Web site
www.palmettogba.com/bsc

Medicare Advisory

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Thank You for Attending!

Any Questions?
The information provided in this workshop was current as
of 10/03/2008. Any changes or new information
superceding the information in this workshop are provided
in articles with publication dates after 10/03/2008 posted
at: www.PalmettoGBA.com/bsc

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