Background: One in every four Medicare nail debridement claims did not include medical-necessity documentation, states an Office of Inspector General (OIG) study. In addition, more than half of these incorrect submissions included other related inappropriate payments.
These findings, however, aren't surprising. "Medicare guidelines can be very confusing on this subject," says Carol Hall, CPC, coding/reimbursement specialist at California Family Health Council in San Diego.
You can avoid OIG scrutiny and simplify coding with these steps: 1. Code Systemic Condition
Foot care coverage depends on a Medicare patient's diagnosis. Medicare will not cover routine foot care "unless the patient is under the active care of a physician for diagnoses such as diabetes mellitus, circulatory system issues, foot infections, fractures, etc.," says Rose Harmon, CPC, coding specialist at Bowdoin Medical Group in South Portland, Maine.
If a patient falls into any of these categories, Medicare may cover foot care services. "Medically necessary foot care services could include treating corns and calluses, trimming or debriding nails, or treatment of fungal infections," Harmon says.
Without a systemic condition, Medicare considers routine foot care a noncovered service.
Action: "Clinic staff should obtain an advance beneficiary notice notifying patients that the service will not be covered and that the patient is responsible for payment," says Craig S. Culver, CPC, coding and compliance specialist at Providence Physician Group in Everett, Wash.
You would append modifier -GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) to A9270 (Noncovered item or service) to indicate Medicare doesn't cover the service.
For the diagnosis, assign V50.8 (Elective surgery for purposes other than remedying health states, other), according to Noridian Mutual Insurance Company's local medical review policy (LMRP) (Part B for 11 western states).
2. Denote Findings With Q Modifier But a systemic diagnosis often isn't the only thing a patient needs to qualify for routine foot care.
A patient must also exhibit a symptom indicating the systemic disease's peripheral involvement. "To indicate the systemic findings, you assign one of the -Q7 to -Q9 modifiers to the CPT code, such as CPT 11720 (Debridement of nail[s] by any method[s]; one to five), says Lisa S. Paul, CPC, podiatry coding specialist at American Billing Systems in Poplar Grove, Ill.
The modifiers range from major to minor findings and denote:
One Class A finding - Q7
Two Class B findings - Q8
One Class B and two Class C findings - Q9. Warning: Even though you don't have to identify the specific findings on the CMS-1500 form, [...]