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Podiatry Billing Guide 


Podiatry Coding Tips

Coding Information

  • Procedure codes may be subject to NCCI edits or OPPS packaging edits. Refer to CCI and OPPS requirements prior to billing Medicare.
  • For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
  • A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.
  • The diagnosis code(s) must best describe the patient's condition for which the service was performed.

ABN Modifier Guidelines

An ABN may be used for services which are likely to be noncovered, whether for medical necessity or for other reasons. Refer to the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 30, (1 MB) for complete instructions.

CPT Coding

Codes 11055, 11056, 11057, 11719, 11720, 11721 and G0127 should be billed with a unit of “1” regardless of the number of lesions or nails treated.

Modifiers

One of the modifiers listed below must be reported with codes 11055, 11056, 11057, 11719, G0127 and with codes 11720 and 11721 when the coverage is based on the presence of a qualifying systemic condition, to indicate the class findings and site:

  • Modifier Q7: One (1) Class A finding
  • Modifier Q8: Two (2) Class B findings
  • Modifier Q9: One (1) Class B finding and two (2) Class C findings

Note: If the patient has evidence of neuropathy, but no vascular impairment, the use of class findings modifiers is not necessary.

Date Last Seen by Attending Physician

ICD-10-CM codes which fall under the active care requirement.

The approximate date when the beneficiary was last seen by the M.D., D.O., or qualified nonphysician practitioner who diagnosed the complicating condition (attending physician) must be reported in an eight-digit (MM/DD/YYYY) format in Item 19 of the CMS-1500 claim form or the electronic equivalent.

Liability for Routine Foot Care

For a routine foot care claim, when the date last seen is more than six months prior to the date of service, the claim will deny patient responsibility because it does not meet Medicare criteria.

If the date last seen by the patient’s attending physician does not meet Medicare criteria, i.e. during the six-month period prior to the rendition of the routine-type service, then the claim will deny for coverage and will make the claim beneficiary responsibility (PR).

For routine foot care services, the date last seen by the patient’s attending physician and the supervising NPI are required on the claim for certain diagnoses. If this information is not entered on the CMS-1500 claim form/electronic equivalent, it is considered “missing information” and the claim will be returned as unprocessable which assigns responsibility to the provider (CO).

Name and NPI of the Attending Physician

The NPI of the attending physician must be reported in Item 19 of the CMS-1500 claim form or electronic equivalent.

When the patient’s condition is designated by an ICD-9-CM code with an asterisk (*) (see ICD-9-CM Codes That Support Medical Necessity in LCD L26426 and on or after 10/1/2015 see ICD-10-CM codes in LCD L33636), routine foot care procedures are reimbursable only if the patient is under the active care of a doctor of medicine or osteopathy (MD or DO) or qualified nonphysician practitioner for the treatment and/or evaluation of the complicating disease process during the six- month period prior to the rendition of the routine-type service.

Podiatry Coding Tips
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