Podiatry Care

Affected Providers

A doctor of podiatric medicine, doctor of medicine, or doctor of osteopathy who bills for Medicare Part B podiatric services.

HCPCS & CPT Codes

Billing and Coding: Routine Foot Care has the current HCPCS and CPT codes. Select your Medicare Administrative Contractor’s (MAC’s) article from the search results.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for podiatry care is 11.2%, with a projected improper payment amount of $216.9 million.

Denial Reasons

Insufficient documentation accounted for 76.4% of improper payments for podiatric providers during the 2024 reporting period, while incorrect coding (11.5%), no documentation (7.2%), medical necessity (4.4%), and other errors (0.6%) also caused improper payments. “Other” errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Preventing Denials

We don’t cover foot care services we consider routine, including:

• Cutting or removing corns and calluses
• Trimming, cutting, clipping, or debriding nails
• Other hygienic and preventive maintenance care (for example, cleaning and soaking the feet, using skin creams to support skin tone of either ambulatory or bedfast patients, and other services done without localized illness, injury, or symptoms involving the foot)

Exceptions to Routine Foot Care Exclusion

Necessary & Integral Part of Otherwise Covered Services

In certain circumstances, we may cover services we ordinarily consider routine if they’re necessary and integral to otherwise covered services (for example, diagnosing and treating ulcers, wounds, or infections).

Treatment of Warts on Foot

We cover treatment of warts (including plantar warts) on the foot to the same extent as treating warts located elsewhere on the body.

Presence of Systemic Condition

A systemic condition, like metabolic, neurologic, or peripheral vascular disease, may require diligent routine foot care by a provider. We may cover routine foot care when systemic conditions result in severe circulatory discomfort or areas of reduced sensation in the patient’s legs or feet. In these instances, certain routine foot care procedures (for example, cutting or removing corns and calluses, or trimming, cutting, clipping, or debriding nails) may pose a hazard to patients with system conditions when a non-professional person performs them.

Mycotic Nails

We may cover treatment of mycotic nails without a systemic condition.

We cover treatment for an ambulatory patient with mycotic nails when the physician attending the patient’s mycotic condition documents that:

• Clinical evidence shows toenail mycosis
• The patient has marked ambulation limitation, pain, or secondary infection because of the infected toenail plate’s thickening and dystrophy

We cover treatment for a non-ambulatory patient with mycotic nails when the physician attending the patient’s mycotic condition documents that:

• Clinical evidence shows toenail mycosis
• The patient suffers from pain or secondary infection because of the infected toenail plate’s thickening and dystrophy

For these requirements, documentation means any written information required by the Part B MAC for services we cover. We must be able to verify the information you submit with claims using information in the patient’s medical record. Any information, including that in a form letter and used for documentation purposes, is subject to Part B MAC verification to make sure the information justifies coverage for treating mycotic nails.

Supportive Devices for Feet

We don’t generally cover orthopedic shoes and other supportive devices for the feet, but this exclusion doesn’t apply to a shoe if it’s an integral part of a leg brace and its expense is part of the cost of the brace. Also, this exclusion doesn’t apply to therapeutic shoes provided to patients with diabetes.

Systemic Conditions that May Justify Coverage

Although not intended as comprehensive, these metabolic, neurologic, and peripheral vascular diseases are the most common underlying conditions that may justify routine foot care coverage:

• Diabetes mellitus and associated conditions*
• Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis)
• Buerger’s disease (thromboangiitis obliterans)
• Chronic thrombophlebitis*
• Peripheral neuropathies involving the feet associated with:
  • Malnutrition and vitamin deficiency*
    • Malnutrition (general pellagra)
    • Alcoholism
    • Malabsorption (celiac disease, tropical sprue)
    • Pernicious anemia
  • Carcinoma*
  • Drugs and toxins*
  • Multiple sclerosis*
  • Uremia (chronic renal disease)*
  • Traumatic injury
  • Leprosy or neurosyphilis
  • Hereditary disorders
    • Hereditary sensory radicular neuropathy
    • Angiokeratoma corporis diffusum (Fabry Disease)
    • Amyloid neuropathy

*We cover routine procedures if the patient is under the active care of a doctor of medicine or osteopathy who documents the condition.

Presumption of Coverage

In evaluating whether Medicare will reimburse the routine services, you may make a coverage presumption when the available evidence shows certain physical or clinical findings consistent with the diagnosis and indicative of severe peripheral involvement.

Class A Findings

Nontraumatic amputation of foot or integral skeletal portion

Class B Findings

• Absent posterior tibial pulse
• Advanced trophic changes like hair growth (decrease or absence), nail changes (thickening), pigmentary changes (discoloration), skin texture (thin, shiny), or skin color (rubor or redness) (3 required)
• Absent dorsalis pedis pulse

Class C Findings

• Claudication
• Temperature changes (for example, cold feet)
• Edema
• Paresthesia (abnormal spontaneous sensations in the feet)
• Burning

We may apply the coverage presumption when the physician providing the routine foot care has identified 1 of the following:

• One Class A finding
• Two Class B findings
• One Class B and 2 Class C findings

Cases that show 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 applying the coverage presumption when a podiatrist has provided the routine services, the Part B MAC may consider the active care requirement met if the claim or other evidence shows the patient saw a physician for treating or evaluating the complicating disease during the 6-month period before starting the routine-type services. The Part A MAC may also accept the podiatrist’s statement that the diagnosing and treating physician concurs with the podiatrist’s findings.