Certificate of Medical Necessity

“As I understand, Medicare no longer requires a Certificate of Medical Necessity (CMN) for Routine Foot Care. Can you please provide me with the actual announcement from Medicare that states that it’s no longer required and the date that it became effective?”

A Certificate of Medical Necessity (CMN) is not required by Medicare for Routine Foot Care, nor has it been required in the past.

When you access the Medicare Coverage Database or MCD, Local Coverage Determination or LCD L35138 thoroughly describes the Limitations, Documentation Guidelines and Utilization Guidelines that need to be followed and present within the medical record for the date of service in question in order to qualify the patient for “At Risk,” Routine Foot Care.

Limitations:

1.      1. When the patient’s condition is designated by an ICD-10-CM code with an asterisk (*) (see ICD-10-CM Codes in the Local Coverage Article: Billing and Coding: Routine Foot Care [A52996]), routine foot care procedures are reimbursable only if the patient is under the active care of a doctor of medicine or osteopathy (MD or DO) or NPP for the treatment and/or evaluation of the complicating disease process during the six (6) month period prior to the rendition of the routine-type service or if the patient had come under a physician’s or NPPS care shortly after the services were furnished.
2.      2. Routine foot care should not be paid in the absence of convincing evidence that non-professional performance of the service would be hazardous for the patient because of an underlying systemic disease.
3.      3. Evaluation and management (E/M) services for any of the conditions defined as routine foot care will be considered ineligible for reimbursement, with the exception of the initial E/M service performed to diagnose the patient’s condition
4.      4. Evaluation and management (E/M) services provided on the same day as Routine Foot Care by the same doctor for the same condition are not eligible for payment except if it is the initial E/M service performed to diagnose the patient’s condition or if the E/M service is a significant separately identifiable service indicated by the use of modifier 25 and documented by medical records.
5.      5. Additionally, whirlpool treatment performed prior to routine foot care to soften the nails or skin is not eligible for separate reimbursement.

Documentation Guidelines:

1.      1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
2.      2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name dates of service[s]). The record must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
3.      3. The submitted medical record should support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code should describe the service performed.
4.      4. The Medical record documentation must support the medical necessity of the services as stated in this policy.
5.      5. Routine foot care services performed more often than every 60 days will be denied unless documentation is submitted with the claim to substantiate the increased frequency. This evidence should include office records or physician notes and diagnoses characterizing the patient’s physical status as being of such an acute or severe nature that more frequent services are appropriate.
6.      6. For foot-care services covered by virtue of the presence of a qualifying, covered systemic disease (asterisked and non-asterisked elsewhere in the Internet-Only Manual, the LCD and the corresponding Local Coverage Article). Medicare expects the clinical record to contain a sufficiently detailed clinical description of the feet to provide convincing evidence that non-professional performance of the service is hazardous to the patient. For this purpose, documentation limited to a simple listing of class findings is insufficient. Medicare does not require the detailed clinical description to be reported at each instance of routine foot care when an earlier record continues to accurately describe the patient’s condition at the time of the foot care. In such cases, the record should reference the location (i.e., date of service) in the record of the previously recorded detailed information. Further, detailed information so referenced should be made available to Medicare upon request.

The patient’s record must include the following:
*Location of each lesion treated.
*identification (by number or name) and description of all nails treated.

7.      7. To distinguish debridement from trimming or clipping, Medicare expects records to contain some description of the debridement procedure beyond simple statements such as “nail(s) debrided.”
8.      8.  For routine foot care and debridement of multiple symptomatic nails to people who have a qualifying systemic condition, the records should demonstrate the necessity of each service considering the patient’s usual activities.
9.      9. Documentation of foot-care services to residents of nursing homes not performed solely at the request of the patient or patient’s family/conservator must include a current nursing facility order (dated and signed with date of signature) for routine foot-care service issued by the patient’s supervising physician that describes the specific service necessary. Such orders must meet the following requirements:

*The order must be dated and must have been issued by the supervising physician prior to foot-care services being rendered.
*Telephone or verbal orders not written personally by the supervising physician must be authenticated by the dated physician’s signature within a reasonable period of time following the issuance of the order.
*The order must be for medically necessary services to address a specific patient complaint or physical finding.
*Routinely issued or “standing” facility orders for routine foot-care services and orders for non-specific foot-care services that do not meet the above requirements are insufficient.
*Documentation of foot-care services to residents of nursing homes performed solely at the request of the patient or patient’s family/conservator should indicate if the request was from the patient or the patient’s family/conservator. When the request is from someone other than the patient the documentation should identify the requesting person’s relationship to the patient.

10. There must be adequate documentation to demonstrate the need for routine foot care services as outlined in this determination. This documentation may be office records, physician notes or diagnoses characterizing the patient’s physical status as being of such severity to meet the criteria for exceptions to the Medicare routine foot care exclusion.

Utilization Guidelines:

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
The frequency of routine foot care varies among patients. Medicare will cover routine foot care as often as is medically necessary but no more often than every 60 days.
Notice: This LCD imposes utilization guideline limitations. Despite Medicare’s allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical records. Medicare expects that patients will not routinely require the maximum allowable number of services.

This is my opinion.

Michael G. Warshaw

DPM, CPC

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