Can an Unlicensed Individual Perform Nail Debridements Under the License of a DPM and Can the Service be Billed to Medicare?
I think I already know the answer to this question, but I would like clarification and “back-up” if you will! It is my understanding that only MDs, DPMs, APRNs, or PAs are allowed to perform and bill these procedures, (in office), to MCR when all the other criteria has been met.
Recently, I have been asked about a nail technician performing these procedures under the supervision of an MD or DPM and billing MCR 11720 or 11721 as Incident to. I have found no information to suggest that is appropriate.
Am I correct in stating that nail technicians or medical assistants are not qualified to perform this service and it get billed as Incident to the provider to MCR?
The issue that you have brought up is one that has been floating around my profession for years. Is it appropriate for a nail technician or a podiatric/medical assistant to perform nail care/debridement of mycotic nails (ie. 11720/11721) in the office of a podiatrist and the service to be billed by the podiatrist? There are a few points of interest.
1. A nail technician or a podiatric/medical assistant is not a licensed individual. Therefore, if they perform this service in the office of a podiatrist, it is not "incident to," but, it is being performed under the license of the podiatrist. Therefore, it is important and a requirement for the podiatrist to either call the state medical board/podiatry board in the state where he or she practices or access the website of the state medical board/podiatry board in the state where he or she practices and obtain in WRITING whether or not within/under the scope of a podiatrist, is it appropriate for an unlicensed individual, specifically a nail technician or a podiatric/medical technician to perform nail care/debridement and for the service to be billed under the license of the podiatrist.
2. When covered nail care is performed and billed to Medicare, when the patient obtains their copy of the EOB, it clearly states the following:
a. The date of service and the CPT code billed (ie. 11720/11721). Adjacent to the CPT code in big, black letters is the word SURGERY. "Sally the 18-year-old medical assistant cut my nails and it was billed as surgery!"
b. On the first page of the patient's copy of the EOB it states the following: "Watch out for health care Fraud." An 800-telephone number is listed to report any "fraud" by the providing physician. If the podiatrist does not have hard copy proof that a nail technician or podiatric/medical assistant is permitted to perform the service under the license of the podiatrist, how can this be defended? It would be very difficult.
3. The debridement of mycotic toenails is covered by Medicare 2 ways:
a. The otherwise healthy individual. Nail debridement is based upon symptoms (ie. pain, difficulty with ambulation, secondary infection).
b. The "At Risk," Routine Foot Care Patient. This is based upon a covered systemic disease and what is referred to as "Class Findings." Class findings are the associated complication(s) resulting from the disease (The Class Findings direct you to select the appropriate Q modifier that needs to be appended to the CPT code/codes that are billed). Per Medicare, the reason that "At Risk," Routine Foot Care is covered is since if an "unlicensed individual" or the patient performs the nail debridement, for example, the patient runs the risk of infection or loss of limb. I believe that this would be problematic, not only from a Medicare standpoint, but also from a medical-legal standpoint if an unlicensed individual performs the service without approval from the state medical or podiatry board.
I hope that this helps.
This is my opinion.
Michael G. Warshaw
DPM, CPC
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