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Medicare and Podiatry Claims

  1. #1
    Location
    Overland Park, KS
    Posts
    1,166
    Default Medicare and Podiatry Claims
    Medical Coding Books
    We have an issue at one of our clinics that I would like imput on, please.

    Medicare patients are coming in to the practice in order to have his or her toenails trimmed. The coders are coding this with the diabetes codes. They tell me that they were told to code diabetes on the claims in order for this procedure to be paid. There is no mention of diabetes in the dictation from the provider and it certainly is not addressed, but Medicare denies this service unless diabetes is the diagnosis.

    My concern here is pretty obvious. They are coding for the sole purpose of getting paid. I feel that the diagnosis should be whatever the reason is that the patient needs his or her toenails trimmed for and if Medicare denies the claim as noncovered, then this is the patient's responsibility.

    My questions are:

    1. What is the correct guidelines from Medicare regarding podiatry and toenail trimmings? Are they to be using DM as the diagnosis? Have I missed something?

    2. Can anyone point me in the right direction of the Medicare guidelines for podiatry and toenail trimmings?

    Thanks.
    Last edited by dballard2004; 09-02-2008 at 11:15 AM.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  2. #2
    Default
    Not my area of expertise, but if there is no documentation nowhere in the chart to support the diabetes dx and they are just using it to get paid, to me that is 'fraud '
    NoRaX

  3. #3
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    not my area of expertise either - but how on earth could they code DM/related if the patient doesn't have DM? {just shaking my head - no, no, no, no, no }
    In my experience, (when we had a podiatrist)Medicare rarely (if ever) covered podiatry only charges. Usually, when the patients needed their nails trimmed there was always something else going on also so there was an office visit and other issues. (with their regular doctor) We still coded the nail trimming, but it was rarely (again, if ever) covered.

    regardless - it's just completely wrong (if not fraudulent) to give them a DM related code to "try" to get it covered. Not every elderly (or Medicare covered) patient has DM. (my dad doesn't). and I'd be pretty irate to come across a bill that claims my father has a DM related condition when he doesn't have DM! (in fact, that would make insurance people correct when they say what they always say: "the coders coded it wrong") ewww.{that's my opinion on the posted matter}
    Donna, CPC, CPC-H

  4. #4
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    Quote Originally Posted by dballard2004 View Post
    We have an issue at one of our clinics that I would like imput on, please.

    Medicare patients are coming in to the practice in order to have his or her toenails trimmed. The coders are coding this with the diabetes codes. They tell me that they were told to code diabetes on the claims in order for this procedure to be paid. There is no mention of diabetes in the dictation from the provider and it certainly is not addressed, but Medicare denies this service unless diabetes is the diagnosis.

    My concern here is pretty obvious. They are coding for the sole purpose of getting paid. I feel that the diagnosis should be whatever the reason is that the patient needs his or her toenials trimmed for and if Medicare denies the claim as noncovered, then this is the patient's responsibility.

    My questions are:

    1. What is the correct guidelines from Medicare regarding podiatry and toenail trimmings? Are they to be using DM as the diagnosis? Have I missed something?

    2. Can anyone point me in the right direction of the Medicare guidelines for podiatry and toenail trimmings?

    Thanks.
    We have a podiatrist and it is difficult to get her claims paid by Medicare. We have patients sign ABN's for their services. Here is a link that might be helpful. http://www.trailblazerhealth.com/Too...inID=1&id=2788

    CAUTION: NEVER bill for DM if the patient is not diabetic. Your Podiatrist should indicate the treatment is related to DM in the visit note if indeed the patient is diabetic.

    Hope this is helpful. You can PM me if you are interested in discussing the issues we've faced and tried to deal with. Good Luck!
    Lisa
    Lisa Bledsoe, CPC, CPMA

  5. #5
    Location
    Overland Park, KS
    Posts
    1,166
    Default
    My thanks to all of you. I am in complete agreement that this site is coding for the sole purpose of getting the claims paid and that is fraud. I appreciate the insight.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  6. #6
    Location
    ENGLEWOOD/DENVER
    Posts
    2,338
    Default
    I agree with Lisa, they will pay them with great difficulty, but you have to make sure you follow all of the LCD's that go along with them. Its been a really long time since I had to code for podiatry and I dont know if the modifiers even still exist but we also had to use Q modifiers.

    Excellent Link Lisa!! Thanks for refreshing my memory!

    good luck! and make sure the doc is documenting those patients with DM!!
    Last edited by mbort; 09-04-2008 at 10:21 AM. Reason: typo

  7. #7
    Default Medicare and Foot Care
    Please review the following information

    http://www.ngsmedicare.com/NGSMedica...active_lcd.htm

    http://www.ngsmedicare.com/NGSMedica...active_sia.htm

    First of all, I agree that you can only code for dx codes that the patient actually have. Never code just to get paid.

    Secondly, the dx of diabetes alone does not necessarily guarantee payment. Please read the above LCD and guidance article. The patient must have systemic disease with findings in order to have their foot care covered.

    If the patient has no class findings, no active disease processes and you are trimming non diseased, elongated nails, I believe the service is considered routine and is statutorily excluded from coverage.
    Heather Winters, CPC, CFPC

  8. #8
    Location
    Overland Park, KS
    Posts
    1,166
    Default
    Thank you all so very much! This is very helpful!
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  9. #9
    Talking
    True the patient is probably coming to have their nails clipped but if they do not have the primary dx of 703.8 with secondary diabetes and their underlying manifestation it is not going to get paid per medicare guidelines. Other problems you might see is the debridement of a lesion/callus along with the trimming. These codes require a 701.1 primary with the diabetes and manifestation coded second and third. Mcr has been deying the 11719 because the pointers have to be lines correctly, when its second on the claim is could get a 1 or 2 depending on how you coded the claim originally. Mcr will deny if it is not 1, so rebilling is a definite.
    I have been experiencing a lot of footcare difficulties trying to teach our physicians because they do not want to end up charging the patient so they under code. Over or undercoding is not right. I feel bad for the elderly who cant take care of their feet due to diabetes but it is not our call, MCR runs the show.

    Hope this has helped you some.

  10. #10
    Location
    Overland Park, KS
    Posts
    1,166
    Default
    You have helped. Thanks so much for the insight!
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

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