APMA - American Podiatric Medical Association



Medicare Noncovered Services by Podiatrists

The Medicare program does not cover certain foot care services and supportive devices for the feet. This document includes an excerpt from the Medicare Benefit Policy Manual (current as of April 16, 2014) that explains noncovered foot care services for the purpose of highlighting what services may not be billed to the Medicare program. Because Medicare manuals are continually updated, Practice should consult with the current version of the manual before taking any action based on the guidance below. Manuals can be found at .

Foot Care Excluded From Coverage

Chapter 15, Section 290 of the Medicare Benefit Policy Manual provides the following guidelines for noncovered foot care services:

The following foot care services are generally excluded from coverage under both Part A and Part B.

2 Treatment of Flat Foot.

The term “flat foot” is defined as a condition in which one or more arches of the foot have flattened out. Services or devices directed toward the care or correction of such conditions, including the prescription of supportive devices, are not covered.

3 Treatment of Subluxation of Foot.

Subluxations of the foot are defined as partial dislocations or displacements of joint surfaces, tendons ligaments, or muscles of the foot. Surgical or nonsurgical treatments undertaken for the sole purpose of correcting a subluxated structure in the foot as an isolated entity are not covered.

However, medical or surgical treatment of subluxation of the ankle joint (talo- crural joint) is covered. In addition, reasonable and necessary medical or surgical services, diagnosis, or treatment for medical conditions that have resulted from or are associated with partial displacement of structures is covered. For example, if a patient has osteoarthritis that has resulted in a partial displacement of joints in the foot, and the primary treatment is for the osteoarthritis, coverage is provided.

4 Routine Foot Care

Except as provided above, routine foot care is excluded from coverage.

Services that normally are considered routine and not covered by Medicare include the following:

• The cutting or removal of corns and calluses;

• The trimming, cutting, clipping, or debriding of nails; and

• Other hygienic and preventive maintenance care, such as cleaning and soaking the feet, the use of skin creams to maintain skin tone of either ambulatory or bedfast patients, and any other service performed in the absence of localized illness, injury, or symptoms involving the foot.

5 Supportive Devices for Feet

Orthopedic shoes and other supportive devices for the feet general are not covered. However, this exclusion does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics.

This Medicare Benefit Policy Manual section is intended to provide MACs with guidelines for developing local coverage determinations concerning noncovered podiatric services. Each MAC has the option of implementing coverage determinations that either follow the guidelines as recommended or adopt the guidelines in modified form. The Practice will contact the local MAC for specific instruction as to the MAC’s policies.

Exceptions to Routine Foot Care and Supportive Devices Exclusions

In certain circumstances, the Medicare program will cover routine foot care that would normally be a noncovered service, as well as supportive devices for the feet that are otherwise noncovered. This document includes excerpts from the Medicare Benefit Policy Manual (current as of April 16, 2014) that explain when routine foot care may be a covered service, for the purpose of highlighting when it is appropriate to bill for routine foot care. In addition, this document includes excerpts from the Medicare Benefit Policy Manual that provide guidance concerning coverage for orthopedic shoes and other supportive devices for the feet, to promote proper billing for those items and related services. Notwithstanding, the guidance below, local Medicare policies may vary. Accordingly, the Compliance Officer or the Compliance Officer’s designee will consult with the local MAC representative and will obtain applicable local coverage determinations and advise the Practice. Finally, because Medicare manuals are continually updated, Practice should consult with the current version of the manual before taking any action based on the guidance below. Manuals can be found at .

2 Exceptions to Routine Foot Care Exclusion

Chapter 15, Section 290 of the Medicare Benefit Policy Manual provides the following guidelines for providing coverage for routine foot care:

1 Necessary and Integral Part of Otherwise Covered Services.

In certain circumstances, services ordinarily considered to be routine may be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of ulcers, wounds, or infections.

4 Treatment of Warts on Foot.

The treatment of warts (including plantar warts) on the foot is covered to the same extent as services provided for the treatment of warts located elsewhere on the body.

8 Presence of Systemic Condition.

The presence of a systemic condition such as metabolic, neurologic, or peripheral vascular disease may require scrupulous foot care by a professional that in the absence of such condition(s) would be considered routine (and, therefore, excluded from coverage). Accordingly, foot care that would otherwise be considered routine may be covered when systemic condition(s) result in severe circulatory embarrassment or areas of diminished sensation in the individual’s legs or feet.

In these instances, certain foot care procedures that otherwise are considered routine (e.g., cutting or removing corns and calluses, or trimming, cutting, clipping, or debriding nails) may pose a hazard when performed by a nonprofessional person on patients with such systemic conditions.

11 Mycotic Nails.

In the absence of a systemic condition, treatment of mycotic nails may be covered. The treatment of mycotic nails for an ambulatory patient is covered only when the physician attending the patient’s mycotic condition documents that (1) there is clinical evidence of mycosis of the toenail, and (2) the patient has marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

The treatment of mycotic nails for a nonambulatory patient is covered only when the physician attending the patient’s mycotic condition documents that (1) there is clinical evidence of mycosis of the toenail, and (2) the patient suffers from pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

For the purpose of these requirements, documentation means any written information that is required by the carrier in order for services to be covered. Thus, the information submitted with claims must be substantiated by information found in the patient’s medical record. Any information, including that contained in a form letter, used for documentation purposes is subject to carrier verification in order to ensure that the information adequately justifies coverage of the treatment of mycotic nails.

3 Supportive Devices For Feet

Chapter 15, Section 290.B of the Medicare Benefit Policy Manual states that “orthopedic shoes and other supportive devices generally are not covered. However, this exclusion does not apply to such a shoe if it is an integral part of a leg brace and its expense is included as part of the cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics.”

Chapter 15, Section 140 of the Medicare Benefit Policy Manual provides the following guidelines for coverage of therapeutic shoes for diabetics:

“Coverage of therapeutic shoes (depth or custom-molded) along with inserts for individuals with diabetes is available as of May 1, 1993. These diabetic shoes are covered if the requirements as specified in this section concerning certification and prescription are fulfilled. In addition, this benefit provides for a pair of diabetic shoes even if only one foot suffers from diabetic foot disease. Each shoe is equally equipped so that the affected limb, as well as the remaining limb, is protected. Claims for therapeutic shoes for diabetics are processed by the Durable Medical Equipment Regional Carriers (DMERCs).

Therapeutic shoes for diabetics are not DME and are not considered DME nor orthotics, but a separate category of coverage under Medicare Part B. (See §1861(s)(12) and §1833(o) of the Act.).”

4 Definitions

The following items may be covered under the diabetic shoe benefit:

1 Custom-Molded Shoes

Custom-molded shoes are shoes that:

• Are constructed over a positive model of the patient’s foot;

• Are made from leather or other suitable material of equal quality;

• Have removable inserts that can be altered or replaced as the patient’s condition warrants;

• Have some form of shoe closure

2 Depth Shoes

Depth shoes are shoes that:

• Have a full length, heel-to-toe filler that, when removed, provides a minimum of 3/16 inch of additional depth used to accommodate custom-molded or customized inserts;

• Are made from leather or other suitable material of equal quality;

• Have some form of shoe closure; and

• Are available in full and half sizes with a minimum of three widths so that the sole is graded to the size and width of the upper portions of the shoes according to the American standard last sizing schedule or its equivalent. (The American standard last sizing schedule is the numerical shoe sizing system used for shoes sold in the United States.).

3 Inserts

Inserts are total contact, multiple density, removable inlays that are directly molded to the patient’s foot or a model of the patient’s foot and that are made of a suitable material with regard to the patient’s condition.

5 Coverage

1 Limitations

For each individual, coverage of the footwear and inserts is limited to one of the following within one calendar year:

• No more than one pair of custom-molded shoes (including inserts provided with such shoes) and two additional pairs of inserts; or

• No more than one pair of depth shoes and three pairs of inserts (not including the noncustomized removable inserts provided with such shoes).

2 Coverage of Diabetic Shoes and Brace

Orthopedic shoes, as stated in the Medicare Claims Processing Manual, Chapter 20, “Durable Medical Equipment, Surgical Dressings and Casts, Orthotics and Artificial Limbs, and Prosthetic Devices,” generally are not covered. This exclusion does not apply to orthopedic shoes that are an integral part of a leg brace. In situations in which an individual qualifies for both diabetic shoes and a leg brace, these items are covered separately. Thus, the diabetic shoes may be covered if the requirements for this section are met, while the brace may be covered if the requirements of §130 are met.

3 Substitution of Modifications for Inserts

• An individual may substitute modification(s) of custom-molded or depth shoes instead of obtaining a pair(s) of inserts in any combination. Payment for the modification(s) may not exceed the limit set for the inserts for which the individual is entitled. The following is a list of the most common shoe modifications available, but it is not meant as an exhaustive list of the modifications available for diabetic shoes:

• Rigid Rocker Bottoms - These are exterior elevations with apex positions for 51 percent to 75 percent distance measured from the back end of the heel. The apex is a narrowed or pointed end of an anatomical structure. The apex must be positioned behind the metatarsal heads and tapered off sharply to the front tip of the sole. Apex height helps to eliminate pressure at the metatarsal heads. Rigidity is ensured by the steel in the shoe. The heel of the shoe tapers off in the back in order to cause the heel to strike in the middle of the heel;

• Roller Bottoms (Sole or Bar) - These are the same as rocker bottoms, but the heel is tapered from the apex to the front tip of the sole;

• Metatarsal Bars - An exterior bar is placed behind the metatarsal heads in order to remove pressure from the metatarsal heads. The bars are of various shapes, heights, and construction depending on the exact purpose;

• Wedges (Posting) - Wedges are either of hind foot, fore foot, or both and may be in the middle or to the side. The function is to shift or transfer weight bearing upon standing or during ambulation to the opposite side for added support, stabilization, equalized weight distribution, or balance; and

• Offset Heels - This is a heel flanged at its base either in the middle, to the side, or a combination, that is then extended upward to the shoe in order to stabilize extreme positions of the hind foot.

Other modifications to diabetic shoes include, but are not limited to flared heels,

Velcro closures, and inserts for missing toes.

4 Separate Inserts

Inserts may be covered and dispensed independently of diabetic shoes if the supplier of the shoes verifies in writing that the patient has appropriate footwear into which the insert can be placed. This footwear must meet the definitions found above for depth shoes and custom-molded shoes.

6 Certification

The need for diabetic shoes must be certified by a physician who is a doctor of medicine or a doctor of osteopathy and who is responsible for diagnosing and treating the patient’s diabetic systemic condition through a comprehensive plan of care. This managing physician must:

• Document in the patient’s medical record that the patient has diabetes;

• Certify that the patient is being treated under a comprehensive plan of care for diabetes, and that the patient needs diabetic shoes; and

• Document in the patient’s record that the patient has one or more of the following conditions:

o Peripheral neuropathy with evidence of callus formation;

o History of pre-ulcerative calluses;

o History of previous ulceration;

o Foot deformity;

o Previous amputation of the foot or part of the foot; or

o Poor circulation.

7 Prescription

Following certification by the physician managing the patient’s systemic diabetic condition, a podiatrist or other qualified physician who is knowledgeable in the fitting of diabetic shoes and inserts may prescribe the particular type of footwear necessary.

8 Furnishing Footwear

The footwear must be fitted and furnished by a podiatrist or other qualified individual such as a pedorthist, an orthotist, or a prosthetist. The certifying physician may not furnish the diabetic shoes unless the certifying physician is the only qualified individual in the area. It is left to the discretion of each carrier to determine the meaning of ‘in the area’.”

Systemic Conditions Supporting Claims for Otherwise Routine Care and Presumption of Coverage

A number of systemic conditions are identified in Chapter 15 of the Medicare Benefit Policy Manual (current as of April 16, 2014) as conditions that may support Medicare coverage of otherwise routine foot care. In addition, there are certain presumptions of coverage for routine services where there are certain findings. This document reprints the section of Chapter 15 of the Medicare Benefit Policy Manual that identifies these systemic conditions, so that Practice employees will be familiar with them and further understand the circumstances under which billing for routine foot care is appropriate. Because Medicare manuals are continually updated, Practice should consult with the current version of the manual before taking any action based on the guidance below. Manuals can be found at .

1 Systemic Conditions

Section 290.D of Chapter 15 of the Medicare Benefit Policy Manual provides the following information about systemic conditions that may support coverage of routine foot care:

Although not intended as a comprehensive list, the following metabolic, neurologic, and peripheral vascular diseases (with synonyms in parentheses) most commonly represent the underlying conditions that might justify coverage for routine foot care.

• Diabetes mellitus *

• Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis)

• Buerger’s disease (thromboangiitis obliterans)

• Chronic thrombophlebitis *

• Peripheral neuropathies involving the feet –

o Associated with malnutrition and vitamin deficiency*

▪ Malnutrition (general, pellagra)

▪ Alcoholism

▪ Malabsorption (celiac disease, tropical sprue)

▪ Pernicious anemia

o Associated with carcinoma *

o Associated with diabetes mellitus *

o Associated with drugs and toxins *

o Associated with multiple sclerosis *

o Associated with uremia (chronic renal disease) *

o Associated with traumatic injury

o Associated with leprosy or neurosyphilis

o Associated with hereditary disorders

▪ Hereditary sensory radicular neuropathy

▪ Angiokeratoma corporis diffusum (Fabry’s)

▪ Amyloid neuropathy

When the patient’s condition is one of those designated by an asterisk (*), routine procedures are covered only if the patient is under the active care of a doctor of medicine or osteopathy who documents the condition.

2 Presumption of Coverage

Section 290.F of Chapter 15 of the Medicare Benefit Manual provides the following additional guidelines for establishing coverage for routine foot care:

“In evaluating whether the routine services can be reimbursed, a presumption of coverage may be made where the evidence available discloses certain physical and/or clinical findings consistent with the diagnosis and indicative of severe peripheral involvement.

For purposes of applying this presumption the following findings are pertinent:

Class A Findings

Nontraumatic amputation of foot or integral skeletal portion thereof.

Class B Findings

• Absent posterior tibial pulse;

• Advanced trophic changes as: hair growth (decrease or absence) nail changes (thickening) pigmentary changes (discoloration) skin texture (thin, shiny) skin color (rubor or redness) (Three required); and

• Absent dorsalis pedis pulse.

Class C Findings

• Claudication;

• Temperature changes (e.g., cold feet);

• Edema;

• Paresthesias (abnormal spontaneous sensations in the feet); and

• Burning.

The presumption of coverage may be applied when the physician rendering the routine foot care has identified:

1. A Class A finding;

2. Two of the Class B findings; or

3. One Class B and two Class C findings.

Cases evidencing findings falling short of these alternatives may involve podiatric treatment that may constitute covered care and should be reviewed by the intermediary’s medical staff and developed as necessary.

For purposes of applying the coverage presumption where the routine services have been rendered by a podiatrist, the contractor may deem the active care requirement met if the claim or other evidence available discloses that the patient has seen an M.D. or D.O. for treatment and/or evaluation of the complicating disease process during the 6-month period prior to the rendition of the routine-type services. The intermediary may also accept the podiatrist’s statement that the diagnosing and treating M.D. or D.O. also concurs with the podiatrist’s findings as to the severity of the peripheral involvement indicated.

Services ordinarily considered routine might also be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of diabetic ulcers, wounds, and infections.”

Medicare Areas of Concern

The OIG has identified a number of activities involving podiatrists that may implicate improper payments or inducements or constitute false claims. The Practice is committed to refraining from any such activities, to avoid any appearance that the Practice is engaged in any illegal or otherwise inappropriate practices. This document describes the types of activities that have come under scrutiny so that Practice podiatrists and employees can be aware of the potential implications of their actions.

1 POLICY AND PROCEDURE

1 OIG ENFORCEMENT ACTIONS

The following activities involving podiatrists have resulted in OIG enforcement actions, under its authority to exclude providers from Medicare and Medicaid participation:

1 Ordering lymphedema pumps based on receiving kickbacks from medical equipment supply companies;

2 “Upcoding” in the form of submitting claims for services at higher services levels under Current Procedural Terminology codes than is supported by the documentation in the medical record;

3 Billing for orthotics made from foot molds when, in fact, the orthotics were made based on two-dimensional foot tracings;

4 Practicing above and beyond the podiatrist’s scope of practice;

5 Submitting claims for items or services not provided;

6 Performing procedures without consent;

7 Charging patients and payors for procedures not performed;

8 Billing for E&M services in the absence of a separately identifiable E&M service performed;

9 Soliciting patients for “free” treatments; and

10 Billing for medically unnecessary services.

2 PODIATRY SERVICES IN THE LONG-TERM CARE SETTING

The OIG has addressed, in several documents, its concerns about podiatry services rendered in skilled nursing facilities and nursing facilities.

1 Special Fraud Alert

On June 17, 1996, the OIG issued a Special Fraud Alert entitled “Fraud and Abuse in the Provision of Services in Nursing Facilities.” Examples of claims for services not rendered or not provided as claimed were outlined. The fraud alert states: “The OIG has learned about podiatrists whose entire practices consisted of visits to nursing facilities. Non-covered routine care is provided, e.g., toenail clipping, but Medicare is billed for covered services which were not provided or needed. In one case, an investigator discovered suspicious billing for foot care when it was reported that a podiatrist was performing an excessive number of toenail removals, a service that is covered but not frequently or routinely needed. This podiatrist billed Medicare as much as $100,000 in 1 year for toenail removals. Investigators discovered one resident for whom bills were submitted claiming a total of 11 toenail removals.”

The fraud alert conveyed OIG concerns about high-volume visits in which one or more medical professionals may see large numbers of residents in a single day. Excessive visits may mean, to the OIG, that the practitioner may be providing medically unnecessary services or a level of services not of a sufficient duration or scope consistent with the services billed to Medicare or Medicaid.

The OIG indicated that frequent and recurring routine visits are suggestive of fraudulent activities because excessive visits may indicate the provider is billing for services not medically necessary.

The OIG also expressed concern about nursing facilities with an unusually active presence by health care practitioners who are given or request unlimited access to resident medical records. The OIG suspects that such practitioners may be collecting information with which they will submit false claims. Podiatry evaluations in nursing facilities should be prompted by requests by facility clinical staff or attending physicians.

2 Audit Report Regarding a California Podiatrist

In 1998, the OIG issued a report “Audit of Medicare Part B Payments to a Southern California Podiatrist for the Period June 1, 1992 through May 31, 1997 (No. A-09-97-00078, January 1998) (the “1998 Report”). The Report was based on a random sample of 100 claims involving payments for 167 separate services.

The 1998 Report identified E & M codes which were not supported by documented services, evidence of upcoding, billing for procedures not considered medically necessary, and E & M codes for which supporting medical records were unavailable.

The OIG identified misuse of modifier -25, which is to be used to report a procedure and E & M code when the E & M services is one that is above and beyond the usual pre- and postoperative care associated with the procedure performed.

The 1998 Report also discusses the importance of the place of service code. The OIG explained that physician services are billed according to the place of service, distinguishing between a nursing home such as a skilled nursing facility or nursing facility, the patient’s home, or a board-and-care or similar domiciliary care facility. Board-and-care homes or similar domiciliary facilities are not the patient’s home for purposes of identification as a place of service. Neither are such locations the private residence of the patient.

The Current Procedural Terminology Manual contains, within the various codes, estimated times. While the Current Procedural Terminology Manual indicates that these are not definitive as to the amount of time required to support the level of code used, the OIG does look at the number of visits made during a day of services and, in the 1998 Report, has expressed concern. The podiatrist who was the subject of the 1998 Report traveled to three facilities and performed 200 procedures and E&M visits during an 18-hour period. While the podiatrist indicated this could be accomplished during a busy day, the OIG noted its concern that such practice patterns suggest that either inadequate attention was provided to patients or a lesser level of service was provided than was claimed.

In the 1998 Report, the OIG identified instances in which three patients were billed with codes indicating that more than five toenails were cut or debrided, when the patients had previously had one foot amputated.

3 Audit Report Regarding Comprehensive Nursing Facility Assessments

In an October 2000 report, “Trailblazer Health Enterprises, LLC [a Medicare Carrier for five states]; Audit of Medicare Claims by Podiatrists and Optometrists for Comprehensive Nursing Facility Assessments for Calendar Years 1995 through 1998” (No. A-09-00-00071, October 2000), the OIG addressed the issue of podiatrists performing comprehensive assessments of skilled nursing facility and nursing facility residents. Each resident admitted to a Medicare skilled nursing facility or Medicaid nursing facility is required to receive an initial physician visit performed by the attending physician within the first thirty (30) days. The OIG determined that, under the scope of practice authorized by local law, podiatrists may not be permitted to provide the comprehensive assessment required of an attending physician. Podiatrists see residents of such facilities at the request of the attending physician. Thus, podiatrists are to bill one of the three “subsequent visit” Current Procedural Terminology codes at 99311-99313 and only the comprehensive visit codes at 99301— 99303 .

It should be noted that HCFA Transmittal 1690, issued by HCFA in January 2001, provides further detail on when initial assessment, subsequent visit, and discharge billing codes are used to identify a patient’s home, when the patient resides in a board-and care-home, or when the patient resides in a skilled nursing facility or nursing facility. Podiatrists not authorized under local law to perform a comprehensive assessment should not bill for those associated codes and should properly identify the place of service.

2 OTHER AREAS OF CONCERN

1 Electrodiagnostic Testing

In April 2014, the OIG issued a report, “Questionable Billing for Medicare Electrodiagnostic Tests” (OEI-04-12-00420) and shared results of its investigation into the billing for electrodiagnostic testing, a test used to evaluate patients who may have nerve damage. Based on its investigation, the OIG concluded that such testing is an area vulnerable to fraud, waste and abuse.

The OIG examined the billing practices of physicians who billed for electrodiagnostic testing in 2011 by applying the following “measures” to determine which physicians met or exceeded a specified threshold:

• Percentage of electrodiagnostic test claims using modifier 59;

• Percentage of electrodiagnostic test claims using modifier 25;

• Percentage of electrodiagnostic test claim;

• Percentage of electrodiagnostic test claims that did not include both a nerve conduction test (NCT) and a needle electromyography (EMG) test;

• Average number of miles between the physicians’ and beneficiaries’ locations;

• Percentage of beneficiaries for whom at least three physicians billed Medicare for electrodiagnostic tests; and

• Number of electrodiagnostic test claims for the same beneficiary on the same day.

Of the over 21, 000 physicians who billed for electrodiagnostic testing in 2011, the OIG determined 23% had questionable billing practices. Of these physicians, 49% were physicians with special training in electrodiagnostic medicine (physiatrists and neurologists) and the remaining 51% were physicians in other specialties such as internal medicine, family medicine, orthopedic surgery and podiatry. The report specifically notes that those in the “other specialties” list are identified by the American Association of Neuromuscular & Electrodiagnostic Medicine as specialties that generally do not have expertise in electrodiagnostic testing. The Medicare billings associated with the questionable billings totaled $139 million dollars.

The OIG recommended that CMS: (a) monitor billing for electrodiagnostic testing; (b) provide education and guidance to physicians in this area; and (3) take action against those physicians the OIG identified as having inappropriate or questionable billing.

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