Routine Foot Care

“How are we supposed to bill CPT 11057 to Medicare to get paid? For the typical patient, we currently use the ICD-10-CM codes E11.42, E11.51, L84, R26.2. We bill this as its own claim. We put the podiatrist as the referring physician. We do not use any modifiers and we previously used the Q8 Modifier when appropriate, but it was denied. What does the proper 1500 form look like for CPT 11057?”

“Medicare sent me a letter about 6 months ago saying I bill CPT 11721 too often compared to CPT 11720 and CPT 11719. However, they consistently deny the combination of CPT 11719 and CPT 11720-59. Not just bundled, but deny both codes, altogether. That then leaves me an outlier with a bunch of CPT 11721 counted and all of the CPT 11719 and CPT 11720 denials left out of the calculations. Appeals are denied (and a waste of time and resources for $11). Their CCI indicator is 1, meaning they can be billed together with 59 or X- modifier on the column 2 code (CPT 11720). Is it fraudulent billing to code only CPT 11720 even though I am debriding 1 to 4 nails and trimming the rest? It also pays more with just CPT 11720 since it is otherwise secondary to a less-than-$11 CPT 11719 code. I hate to turn away these patients who have a true need. Recommendations?”

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

“I am a young physician and the practice that I am currently at codes almost all routine foot care patients as the following: 1. Tinea ungium B35.1, 2. Peripheral Vascular Disease (PVD) I73.9, 3. Pain in left toe. Documentation is all the same: “All nails are thickened, discolored, and painful with subungual debris” with CPT 11721. Basically, there is no individual nail documentation and all nails are always painful with PVD. This includes younger, disabled patients who present with some thickened nails. I was under the impression that you have to document individual nails and that pain alone is a qualifying diagnosis for nails, if used as the secondary code. My question is: wouldn’t coding only CPT 11721, with pain and PVD to all toes all the time raise red flags?”

UNLESS THE FUNGUS INFECTION IN A NAIL REQUIRES DEBRIDEMENT BECAUSE IT CAUSED THE NAIL TO BE ABNORMALLY THICK WHICH RESULTED IN EITHER PAIN OR A SECONDARY INFECTION OR A MARKED LIMITATION OF WALKING, THE TREATMENT SERVICE IS CONSIDERED SIMPLY A NAIL TRIMMING AND IS NOT PAYABLE BY MEDICARE.

Peripheral Neuropathy is the most common factor leading to amputation in people with diabetes. In diabetes, peripheral neuropathy is an anatomically diffuse process primarily affecting sensory and autonomic fibers.

What is the Active Care Requirement regarding “At Risk, Routine Foot Care?

“I am in practice and would like to figure out a different way to contain and manage my routine foot care. It is approximately 15% of my practice. I would like to designate one morning a week as a routine foot care clinic. I am considering making this a cash only clinic: $50 for toenails and $50 for calluses. Is this possible? I am a Medicare provider and have contracts with most insurance companies. I was hoping to model my cash clinic on what some nurses in the area have done. They visit a nursing home and offer residents $25 for routine foot care and do not work with any insurance companies or Medicare. Any thoughts on this cash model, routine foot care clinic would be appreciated.”

​​​​​​​“I have a Medicare patient that has healed a neuropathic ulcer (L97.522, E11.62) at the plantar base of his 5th metatarsal. He needs paring of the hyperkeratotic tissue, frequently with hemorrhagic changes, every four weeks or he re-ulcerates at this location. Should this be coded as: CPT 11055 using a GY modifier every other visit? Debriding devitalized tissue CPT 97597 or am I evaluating and managing an ulcer CPT 9921X?”

“My practice involves a lot of routine foot care and I am looking for clarification. In using Q8 and Q9 modifiers, do you need to have atherosclerotic peripheral vascular disease (ASPVD) as a diagnosis? If so what’s the code to be used for general ASPVD? Modifier Q7 indicates that there has been an amputation. It is not necessary to have an ASPVD diagnosis in that scenario?”