Routine Foot Care in Nursing Homes

Do I need to have a referral to provide Routine Foot Care to a patient in a Nursing Home?

If you go on the MCD (Medicare Coverage Database) website and look up Routine Foot Care, LCD L35138 Routine Foot Care is accessed. When you find the “Documentation Guidelines,” #9 addresses the issue at hand.

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.

Taking this one step further, here is the actual rule that supports the above information.

BASED ON THE SOCIAL SECURITY ACT, SECTION 1862:

MEDICARE WILL NOT COVER ANY SERVICE OR PROCEDURE THAT IS PERFORMED ON A PATIENT OF A NURSING FACILITY UNLESS:

The Patient’s attending physician (MD, DO) evaluates the Patient and authorizes the ORDER for the referral to another provider specialty. (In this situation, a Podiatric Physician),

OR

The Patient or a Patient’s family member, legal guardian or POA requests a NAMED Podiatric Physician to treat the Patient for a specific condition. In this case, the attending Physician must be notified of any change in the Patient’s condition and any need to alter the Patient’s treatment, significantly.

One of these two situations needs to occur and be documented EVERY TIME the DPM treats a patient in the Nursing Facility.

It is important to have an exact copy of what was recorded in the Nursing Facility Chart for the patient treated and keep the copy off the premises of the Nursing Facility. The same applies to the physician’s order or the request of the patient, patient’s family member, legal guardian or POA.

One last issue related to treating a patient in a Nursing Home pertains to the Place of Service Code that is being used to bill for the service that is being provided to the Nursing Home patient. Place of Service Code 31 is for Skilled Nursing Facility and Place of Service Code 32 is for Nursing Facility. Place of Service Code 31, Skilled Nursing Facility or SNF is clearly representative of a facility Place of Service, while Place of Service Code 32, Nursing Facility is representative of a non-facility Place of Service. Facility Place of Service Codes reimburse at a lower rate than Non-facility Place of Service Codes reimburse. Since both Place of Service Codes are available within the same location, that is the Nursing Home, it is imperative that the provider confirms prior to treating the patient what is the correct Place of Service for each patient that is being seen and treated within the Nursing Home.

This is an issue that is being looked at and is being audited by the Medicare Administrative Contractors big time and they are going back 3 years to reclaim reimbursements that were inappropriately overpaid to podiatrists for billing using the wrong Place of Service Code, 32 as opposed to 31.

This is my opinion.

Michael G. Warshaw

DPM, CPC

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