Part B Routine Foot Care Services Questions and Answers

Question: Please help me clarify the HCPCS modifiers Q7, Q8 and Q9. Even if the patient has a diagnosis covered on the LCD, do they still need to meet the criteria for one of those modifiers, or do they need to meet one of those modifiers if they do not have a diagnosis covered on the LCD?

Answer: The HCPCS modifiers Q7, Q8 and Q9 are needed 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 involvement. A diagnosis that is included in the LCD by itself is not sufficient to meet the presumption of coverage. 

Question: If my podiatrist is the one performing the nail debridement, is it sufficient that a family practice physician saw the patient within the last six months?

Answer: When the patient’s condition is one 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.

Active care: The claim or other available evidence must indicate that the patient has seen an M.D. or D.O. for treatment and/or evaluation of the complicating disease process within six months before the routine-type services were rendered.

Question: If the patient only saw a nonphysician practitioner (NPP), can the date the patient last saw that NPP be used to meet the date last seen requirement?

Answer: 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.

Question: What if we only have a nurse practitioner as the primary?

Answer: 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 (M.D.), or osteopathy (D.O.) who documents the condition. If the requirement is not met, the service is not covered.

Question: We are in a very rural area with a healthcare provider shortage. Many of our patients see nurse practitioners (NPs). These NPs prescribe diabetic medications to the patients as well as supplies. How is Medicare attempting to get patients to see M.D.s and D.O.s for their diabetic maintenance? Or can we list the NP's D.O. or M.D. supervisor as the supervising physician for these patients?

Answer: As a Medicare Administrative Contractor, Palmetto GBA is charged with applying CMS coverage to submitted foot care claims. Palmetto GBA does not instruct patients to the practitioners they should seek care from.

When the patient’s condition is one of those designated by an asterisk (*), routine foot care procedures are covered by Medicare only if the patient is under the active care of a doctor of medicine or osteopathy who documents the condition. This must be indicated by the name and national provider identifier (NPI) of the attending physician in block 17 and 17B of the CMS-1500 or the equivalent electronic claim format. The date the patient was last seen by the attending physician should be billed in block 19. Claims for such routine services should show the complicating systemic disease in block 21 of the CMS-1500.

Question: If we bill CPT code 11721 with a diagnosis of diabetes can this code be billed every 60 days?

Answer: Please review the coverage criteria. Covered exceptions to routine foot care services are considered medically necessary once (1) in 60 days. If billing more frequently than the 60 day time period, for patients who are medically at risk, the provider should document the medical necessity of the increased frequency.

Question: Please discuss the need, or lack of need, for a Medicare ABN when providing routine foot care services.

Answer: When a service covered by Medicare is expected to be denied as not medically necessary or provided more frequently than allowed, a provider may execute the Advanced Beneficiary Notice of Noncoverage (ABN). Providers are encouraged to review the CMS ABN Form Instructions (PDF, 88 KB) for proper completion of the ABN form.

Question: Are ABNs required for noncovered routine foot care? If so, how often is it required to be signed?

Answer: Routine foot care is excluded from coverage, except when an individual patient’s condition and circumstances meet CMS identified conditions that might justify coverage. Upon evaluating whether routine services are reimbursable, a presumption of coverage may be made where the evidence available shows certain physical and/or clinical findings are consistent with the diagnosis and indicate severe peripheral involvement. Refer to the Medicare Benefits Policy Manual, Chapter 15, Section 290 (PDF, 1.37 MB). When the service is noncovered, no ABN is required but may be voluntarily provided.

Question: Can Medicare train their reps to inform patients when a call is placed asking if routine foot care is covered to inform them that there are certain guidelines and criteria that have to be met and that is determined by the provider instead of the reps telling the patients that routine is a covered benefit for them?

Answer: The beneficiary contact center (800–Medicare) handles all patient inquiries and is aware and has access to the Palmetto GBA local coverage determination and the CMS coverage guidelines.

Question: In what capacity can a podiatric nail tech be utilized with nail debridement after the first debridement with a M.D.?

Answer: In order to bill the services of any ancillary staff, all of the incident to requirements must be met. Please review those guidelines for any application to your specific circumstances. Internet Only Manual, Publication 100-2, Chapter 15, Sections 60.1 – 60.4 (PDF, 1.37 MB).

Question: Can you confirm that the frequency rule pertains to a whole foot care visit and not one foot care code per 60 days?

Answer: Routine foot care services are considered medically necessary once (1) in 60 days.

Question: Where can I find a list of the diagnosis codes with an asterisk (*) listed?

Answer: Local Coverage Determination L37643, or CMS Internet Only Manual, Publication 100-2, Chapter 15, Section 290 (PDF, 1.37 MB).  

Question: In regard to podiatry errors, what do you mean by projected improper payment amount? Are you saying providers billed the wrong amount?

Answer: An improper payment is any payment that should not have been made or that was made in an incorrect amount under statutory, contractual, administrative or other legally applicable requirements. CMS calculates improper payment rates from the sample of claims reviewed by the Comprehensive Error Rate Testing (CERT) contractor. The improper payment rate calculated from a sample is considered to reflect all claims processed by the Medicare fee-for-service program during the reporting period.

Question: What about the XS, XU, XE, XP HCPCS HCPCS modifiers?

Answer: These HCPCS modifiers are outlined in the Palmetto GBA Palmetto GBA Modifier Lookup Tool.  

• XE — Separate Encounter, a service that Is distinct because it occurred during a separate encounter
• XP — Separate Practitioner, a service that is distinct because it was performed by a different practitioner
• XS — Separate Structure, a service that is distinct because it was performed on a separate organ/structure
• XU — Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service

Question: On the slide it states that the patient has to see an M.D. or D.O. A great deal of the patients come in and they state that they see the PA or NP in that office and never see the M.D. or D.O. Would that patient be considered a self-pay patient and need to fill out the ABN for non-covered services?

Answer: When the criteria for covered routine foot care is not met, a provider may choose to use the Advanced Beneficiary Notice (ABN) to notify the patient of their financial liability.

Question: Is DLS a requirement for PVD coding?

Answer: No, it is not a requirement to document diabetic loss of sensation (DLS) as a prerequisite of a diagnosis of peripheral vascular disease. Peripheral vascular disease can occur in non-diabetics and can be manifested by signs and symptoms other than loss of sensation and neuropathy, i.e., coldness, pale or blue skin color and trophic changes such as loss of hair and thinning of skin, diminished pulses, and others.

Question: Is a nail biopsy/culture necessary to document the mycotic infection?

Answer: At the current time, documented evidence of a mycotic nail infection is required, a culture could contribute to that documentation but it is not required.

Question: Do we have any specific diagnosis code sequencing order required to be reported for CPT 11055, 11056 or 11057?

Answer: We would encourage providers to list the primary reason for the encounter first.

Question: If the patient is not seeing a M.D. or D.O. for their condition, but would qualify, what's the best way to bill that?

Answer: If the patient’s condition is one noted with an (*) and the patient has not been seen by an M.D. or D.O. for that condition within the previous six months, the service would be considered non-covered. While not mandated, the Advance Beneficiary Notice (ABN) may be provided to Medicare patients as a courtesy, to inform them of their financial responsibility for services that are statutorily excluded from Medicare benefits. Statutorily excluded services are services that, by law, Medicare cannot pay for.

Question: What documentation is needed to document pain for mycotic/dystrophic nail care?

Answer: There is no set prescriptive for documenting pain. Providers are encouraged to assess a patient’s pain and document findings including, but not limited to: onset, contributing factors, quality, severity, radiation (if present), temporal factors and patient impact.

Question: Does the E/M info have to be in the patient's medical record in general or relisted for every covered routine foot care service?

Answer: The medical record should include documentation to support the patient is under the active care of an M.D. or D.O. for the treatment and/or evaluation of the complicating disease process and has seen that physician within the six months prior to any routine foot care service.

The claim must indicate that the patient has seen an M.D. or D.O. for treatment and/or evaluation of the complicating disease process within six months before the routine-type services were rendered.

Question: Earlier this year, Palmetto GBA Virginia region started denying routine foot care claims that were not coded properly according to today's guidelines. But then due to numerous podiatry complaints they stopped the claim edits. Are they now going to resume these revised claim edits and errors? It is okay if so, but I need to notify our podiatrists.

Answer: Podiatry claim editing has been in place since the Routine Foot Care local coverage determination was effective. The editing has never been stopped. The issues causing the inappropriate denials were addressed.

Question: I want to ask if HCPCS modifier GY or GZ should be used if a service is not medically necessary.

Answer: Information on HCPCS modifier GY and GZ.

GY — Item or service statutorily excluded or does not meet definition of any Medicare benefit.
GZ — Item or service expected to be denied as not reasonable and necessary and an Advance Beneficiary Notice (ABN) has not been signed by the beneficiary.

Question: Do specific medical risks have to be stated in every note, or just once in the record and then stated as having met Q7 (or Q8/9) findings thereafter?

Answer: 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 and
• The clinical documentation of class findings for each date of service 

Question: What if a patient is new to our clinic and they had routine foot care prior to our visit but we were not aware. Can we appeal that denial?

Answer: Routine foot care services are considered medically necessary once (1) in 60 days. Providers are encouraged to query their patient regarding previously provided routine foot care. If a service is denied as not medically necessary or provided more frequently than allowed, a provider does have appeal rights and must provide documentation to support the medical necessity and frequency of routine foot care services provided.

Question: Does the date last seen have to be the exact date or can we document month and year only? Our elderly patients don't recall exact dates. We would have to turn patients away if you need the exact date they were seen.

Answer: Document the date last seen with as much specificity as available.

Question: What level of "active management" of PAD is required by the listed physician? A condition such as this often can't be actively managed.

Answer: 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. This must be indicated by the name and national provider identifier (NPI) of the attending physician in block 17 and 17B of the CMS-1500 or the equivalent electronic claim format. The date the patient was last seen by the attending physician should be billed in block 19. Claims for such routine services should show the complicating systemic disease in block 21 of the CMS-1500. 

Question: Does Medicare cover the debridement of blocked sweat ducts in the absence of a systemic condition? The patient complains of the sensation of "walking on pebbles.” The procedure is debridement and or curettement with the application of Phenolic Acid — CPT code 17110?

Answer: Medicare does not cover the debridement of blocked sweat ducts in the absence of a systemic condition.

Question: The last seen date and the NPI of the attending physician, should this be the primary care physician if the patient has diabetes and is coming to the podiatrist for foot care?

Answer: This should be the physician or D.O. treating the patient for the systemic condition.

Question: Does there have to be a 59 CPT modifier on HCPCS G0127 code when billing with CPT code 11056 or 11057?

Answer: CPT modifier 59 — distinct procedural service. Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. CPT modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together but are appropriate under the circumstances.

Refer to the Palmetto GBA Modifier Lookup Tool for information regarding modifier 59. The most common use of CPT modifier 59 is to allow separate reimbursement for services that would normally be “bundled” by the Correct Coding Initiative (CCI) edits. Before submitting this modifier, it is important to verify whether the services are bundled through CCI. CCI edits may be updated as often as quarterly. Access the CMS website for the National Correct Coding Initiative.

Question: Since procedures fall under the surgical section of CPT, what is the format for documenting? For example: signed consent, method used, description of procedure, etc.?

Answer: The determining factor in any review of medical records is the content of what is documented in the medical record entry and not how it is documented. Documentation Tips:

• All information about services performed must be documented
• If it isn’t documented, then it wasn’t performed. Reviewers do not know the services provided if there is no documentation.
• You are paid for what you document, not what you did
• More is always better when it comes to documentation

Question: In the state of Alabama we were told the supervising provider could now be the DPM. Is this incorrect?

Answer: We are unclear what is meant by "supervising provider" in this question. If this is referring to the entity providing active care for the patient’s systemic condition, the following applies: 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.

Question: If a non DM patient wants to come in every 4–6 weeks to get nails trimmed can you bill the patient?

Answer: You may bill the patient for statutorily noncovered nail trimming.

Question: Some of our patients are under the impression that because they are taking blood thinners, nail and callus care is covered by Medicare. We cannot find documentation of that, can you elaborate?

Answer: Coverage for routine foot care is based on the patient’s condition/diagnosis. Some of these conditions may involve treatment with blood thinners.

Refer to: 

• Local Coverage Determination (LCD): Routine Foot Care (L37643)
• CMS Internet Only Manual, Publication 100-2, Chapter 15 (PDF, 1.37 MB).  

Question: If we have the treating PCP complete a class findings "form," how long is it good for as long as we get the last visit date each time we see patient?

Answer: The medical record should include the clinical documentation of class findings for each date of service.

Question: What about doctors that under-bill where they do not use CPT code 11721 although provided this service but just bill office visit?

Answer: Medicare would expect providers to accurately bill for the services provided and documented in the medical record. Should it be determined that a provider did not bill correctly, the claim, when brought to our attention of identified through an audit, would represent an overpayment.  

Question: Do the Medicare Managed Care Insurance Plans have to follow your guidelines?

Answer: Medicare Advantage Plans receive their guidance directly from the CMS. It is my understanding a Medicare Advantage Plan can be no more restrictive in coverage than traditional Medicare. Questions about a Medicare Advantage Plan’s coverage should be directed to the individual plan.