Advanced Search

Primary Care Coding Alert

Beat OIG Foot Care Scrutiny With These Coding Tips

Published on Wed Apr 27, 2005

Clear findings support Q modifier - and fend off auditors

You should reserve the foot care codes for cases in which you can clearly point to the Medicare patient's systemic condition and its peripheral involvement. 
 
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, an auditor will want to see that information in the physician's documentation.
     
    3. Put Symptoms in Appropriate Class

     Here are the qualifying symptoms Paul says you should look for:
     
    Class A: "To qualify for Q7, the patient has to have had an amputation," Paul says.
     
    Class B: The patient must either have an absent posterior tibial or dorsalis pedis pulse or three trophic changes. You should count any of the following notations as one appearance change:

  • lack of or increase in hair growth
      
  • thickening nails
      
  • pigmentary discoloration
      
  • thin or shiny skin texture
      
  • skin color inflammation or redness.

     Class C: Don't use modifier -Q9 unless your family physician (FP) documents one class B finding and two of the following:

  • limping
      
  • temperature changes
      
  • edema
      
  • burning
      
  • paresthesia (abnormal sensation).

    Example: A diabetic patient presents with two calluses on her right foot. She complains of cold feet and pain in her calf. The FP determines that the patient lacks a posterior tibial pulse. The physician pares both lesions.
     
    Solution: You would code the appropriate-level office visit (99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient ...) appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). "The physician must perform an E/M service to assess the patient's condition and determine whether the foot care is a billable and payable service," Paul says.
     
    Medicare will cover this routine foot care. The patient meets the systemic disease criteria for diabetes mellitus, as well as one Class B finding (absent posterior tibial pulse) and two Class C findings (claudication and temperature change). So you should report the paring as 11056 (Paring or cutting of benign hyperkeratotic lesion [e.g., corn or callus]; two to four lesions) with modifier -Q9 to indicate the documented class findings.
     
    Also report diagnosis codes 700 (Corns and callosities) and 250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled). The patient has calluses and diabetes without mention of complication, type or instability.

    4. Check Carrier Specifics

    Because insurers vary on acceptable diagnoses and submission requirements, research your Medicare carrier's policy. "Go to your carrier's Web site and pull up its foot care policy," says Quinten A. Buechner, MS, MDiv, CPC, CHCO, president of ProActive Consultants LLC in Cumberland, Wis.
     
    Some variations: You don't need a Q modifier with a diagnosis of peripheral neuropathy (total or near total loss of sensation in the feet) (such as 357.2-357.4, Polyneuropathy in diabetes, malignancy and other diseases) or chronic thrombophlebitis (451.0-451.2), states Noridian's local medical review policy. National Heritage Insurance Company's policy states only that you should use modifiers -Q7 to -Q9 "when applicable."
     
    Most of Medicare's foot care issues, however, fall under a national coverage determination (NCD). "So carriers treat many foot care procedures the same," Buechner says.
     
    To read the NCD, download the file at www.cms.hhs.gov/manuals/pm_trans/B02091.pdf.

    • Other Articles in this issue of

    Primary Care Coding Alert

    View All