Primary Care Coding Alert

Question: A Medicare diabetic patient presents for nail trimming of onychonosus nails. Would the carrier consider the procedure routine foot care? If not, which CPT and ICD-9 codes should I use to ensure coverage? Vermont Subscriber Answer: Medicare considers trimming nails routine foot care and limits coverage to patients who have complicated systemic diseases with severe peripheral involvement that make nonprofessional treatment hazardous. Depending on the carrier, the claim would have to contain an accepted diabetes mellitus diagnoses and the appropriate number of class findings. To find out if the patient has a covered diagnosis, you should check your carrier's local medical review policy (LMRP). For instance, National HeritageInsurance Company (NHIC), the Medicare Part B carrier for Maine, Vermont, New Hampshire and Massachusetts, covers routine foot care for claims that contain diagnosis codes for diabetes mellitus with complications, including diabetes with:
renal manifestations (250.40-250.43)
ophthalmic manifestations (250.50-250.53)
neurological manifestations (250.60-250.63)
peripheral circulatory disorders (250.70-250.73). The family physician (FP) must document that the patient has signs and symptoms that fall into one of three classes. To qualify for coverage, the medical record must indicate:
one class-Afinding:
  o non-traumatic amputation of foot or integral skeletal portion
two class-B findings: 
  o absent posterior tibial pulse
  o absent dorsalis pedis pulse
  o advanced trophic changes such as (three trophic changes are required to meet one class finding):
        hair growth (decrease or absence)
       nail changes (thickening)
       pigmentary changes (discoloration)
        skin texture (thin, shiny)
        skin color (rubor or redness)
        or one class-B and two class-C findings:
  o claudication
  o temperature changes (for example, cold feet)
  o edema 
  o paresthesia (abnormal spontaneous sensations in the feet)
  o burning. If documentation supports Medicare coverage of the nail trimming, you should report 11719 (Trimming of nondystrophic nails, any number) or G0127 (Trimming of dystrophic nails, any number) depending on whether the nails were nondystrophic or dystrophic. Append the procedural code with the modifier that indicates the proper amount of findings: -Q7 (One class-A finding), -Q8 (Two class-B findings) or -Q9 (One class-B and two class-C findings). Link the procedure to the diabetes diagnosisand put 703.8 (Diseases of nail; other specified diseases of nails) in the secondary position. Although NHIC's LMRP suggests listing the systemic disease first, you should check with other carriers for their policies.