Professional Documents
Culture Documents
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
Medicares Definition of
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
*carcinoma
*diabetes mellitus
*drug or toxins
*multiple sclerosis
traumatic injury
Leprosy & neurosyphilis
Hereditary disorders (Fabrys), amyloid
neuropathy)
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
Nail hypertrophy
Lysis
Discoloration of the nail
Brittleness
Loosening of the nail plate
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
UNNAs Boot
Procedure 29580 covered for DX:
4402.23
454.2
707.10 - 707.19
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
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
XXXXXXXXXX
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No modifiers required
An E/M will deny without a -25 modifier
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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
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May 2008
Claims submitted in the 12 month period
ending September 30 3007
74.3%
7.3%
9.4%
No Documentation
Insufficient
Documentation
Medically Unnecessary
Services
Incorrect Coding
November 2007
18.4%
No Documentation
8.0%
Insufficient
Documentation
Medically Unnecessary
Services
Incorrect Coding
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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
Medically Unnecessary
Services Errors
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Coding Errors
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www.palmettogba.com/bsc
16
Call 1-866-238-9654
Payment Floor
Claim Information
Order a Duplicate
Remittance
Beneficiary Entitlement
Beneficiary Part B
Deductible
17
Medicare Advisory
18
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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