Routine Foot Care General Information

Are There Any Exceptions to this Rule?
Yes, Medicare allows exceptions to this exclusion when medical conditions exist that place the beneficiary at increased risk of infection and/or injury if a non-professional would provide these services. Medicare may cover routine foot care in the following situations:

• The routine foot care is a 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.

• The patient has a systemic condition

The presence of a systemic condition such as metabolic, neurologic or peripheral vascular disease may result in severe circulatory embarrassment or areas of diminished sensation in the individual’s legs or feet. In these instances, certain foot care procedures that otherwise are considered routine (as defined previously) may pose a hazard when performed by a nonprofessional person.

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
• Buerger’s disease
• Chronic thrombophlebitis *
• Peripheral neuropathies involving the feet

Associated with malnutrition and vitamin deficiency *

• Malnutrition
• Alcoholism
• Malabsorption
• Pernicious anemia
• Associated with carcinoma *
• Associated with diabetes mellitus *
• Associated with drugs or toxins *
• Associated with multiple sclerosis *
• Associated with uremia (chronic renal disease) *
• Associated with traumatic injury
• Associated with leprosy and neurosyphilis
• Associated with hereditary disorders
• Hereditary sensory radicular neuropathy
• Angiokeratoma corporis diffusum (Fabry’s)
• Amyloid neuropathy

When the patient’s 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.

Class Findings
Routine foot care may be covered when "class findings" related to one or more of the preceding diagnoses are documented and the appropriate HCPCS modifier is submitted. Documentation must include clear evidence of significant circulatory changes (one of the following):

• 1 Class A finding (submit HCPCS modifier Q7)
• 2 Class B findings (submit HCPCS modifier Q8)
• 1 Class B and 2 Class C findings (submit HCPCS modifier Q9)

Class A Findings

• Nontraumatic amputation of foot or integral skeletal portion thereof

Class B Findings

• Absent posterior tibial pulse
• Absent dorsalis pedis pulse
• Advanced trophic changes (at least three of the following):
  • 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 (cold feet)
• Edema
• Paresthesia (abnormal spontaneous sensations in feet)
• Burning

Documentation for Systemic Conditions/Class Findings
Palmetto GBA does not require any documentation to be submitted with claims for routine foot care services. However, there must be evidence that the patient was under the care of a doctor of medicine or osteopathy during the preceding six months. Therefore, the National Provider Identifier (NPI) of this doctor and the date of the last visit to this doctor must be submitted on claims for routine foot care.

• Electronic claims: submit the NPI of the doctor of medicine or osteopathy in Loop 2310E or 2420D, NMI/DQ, 09 and the date of the last visit to this doctor in Loop 2300 or 2400, DTP/304, 03
• Paper claims: submit this information in Item 19 of the CMS-1500 claim form  

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   

Mycotic Nails
Ambulatory patients:

• Treatment of mycotic nails may be covered in the absence of a systemic condition, when certain conditions are met 
• Treatment of mycotic nails for an ambulatory patient is covered only when the physician attending the patient’s mycotic condition documents that there is clinical evidence of mycosis of the toenail, and the patient has marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate   

Nonambulatory patients:

• Treatment of mycotic nails for a nonambulatory patient is covered only when the physician attending the patient’s mycotic condition documents that there is clinical evidence of mycosis of the toenail, and 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 carrier in order for services to be covered. Thus, the information submitted with claims must be substantiated by information found in the patient’s medical record. Any information, including that contained in a form letter, that is used for documentation purposes is subject to carrier verification in order to ensure that the information adequately justifies coverage of the treatment of mycotic nails.

Frequency
Services performed for excessive frequency are not medically necessary. Routine foot care services are considered medically necessary one time in 60 days.

Non-Covered Care and Claim Submission
Claims for "routine foot care" are not covered when the coverage provisions for routine foot care are not met (i.e., there is no clinical evidence that the performance of these procedures by a non-professional would pose a hazard to a patient with a systemic disease that has resulted in severe circulatory embarrassment or areas of desensitization in the legs and feet). These non-covered services are not subject to limiting charge restrictions or waiver of liability and you may bill patients for these services:

1. Services denied because they are not Medicare benefits or because Medicare law specifically excludes payment for the services
2. Services denied because they do not meet all the requirements of the definition of a benefit in Medicare law

Obligation to Bill Non-Covered Services

• Ordinarily, a physician or healthcare provider does not submit a claim for non-covered services. However, if the beneficiary (or his/her representative) believes that a service may be covered or desires a formal Medicare determination, the physician or healthcare provider must file a claim for that service to effectuate the beneficiary's right to a determination.
• Submit HCPCS modifier GY to denote that "the item or service is statutorily excluded or does not meet the definition of any Medicare benefit." Maintain documentation that the service is being submitted at the beneficiary's insistence. You may also submit HCPCS modifier GY when filing claims to obtain a Medicare denial for secondary payer purposes.

• Both Medicare beneficiaries and providers have certain rights and protections related to financial liability under the fee-for-service (FFS) Medicare and the Medicare Advantage (MA) Programs. These financial liability and appeal rights and protections are communicated to beneficiaries through notices given by providers.
• The only acceptable ABN form for Medicare purposes is the CMS ABN form, available on the CMS website
• The ABN form must be presented to the beneficiary before the service or procedure is initiated. Maintain a completed and signed copy of the form in the medical record.
• It is not appropriate to use ABNs every time, for all services and for all beneficiaries

Guidelines/Instructions

• Submit HCPCS modifier GA when there is a valid ABN on file for the service
  • HCPCS modifier GA may not be submitted with services that are statutorily excluded
• Submit HCPCS modifier GY with items or services that are statutorily excluded or that do not meet the definition of any Medicare benefit
  • HCPCS modifier GY may be appropriate when routine foot care does not meet Medicare coverage
  • You may offer the beneficiary a CMS ABN. This form is optional for services that are statutorily excluded from Medicare coverage. 

Reference