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Some have termed this the “Comprehensive Diabetic Foot Exam” and believe that this is a reimbursable event under Medicare.Dr. Freedman is mostly correct in that Medicare does not cover this type of exam.The one exception is for Loss of Protective Senstation (LOPS) exams. Under this coding, Medicare does provide for a LOPS exam every six months. There is a rather big however, as patients are excluded from LOPS coverage if they have seen any health care provider for a foot related issue within the past six months for any reason. This can be as simple as a contusion. Any visit to any health care provider for a foot related diagnosis, excludes the patient from LOPS. This exception to the rule hardly helps the vast majority of diabetic patients seeking the care from a podiatrist. In my almost forty years of practice, I would be hard pressed to think of any Medicare aged patients with diabetes who did not have some pathology related finding(s). One example is xerosis. Even if this is the only finding, is related to autonomic neuropathy (does the patient have a cardiac, renal or opthamology issue)? Do they have Chronic Venous Insuffiiciency or Peripheral Vascular Disease effecting the lower extremity? Is it fungal, allergenic, actinic keratosis, pre cancerous, Sq Cell or related to some other dermatological disease? Even if the only treatment is related to ADL’s (e.g. change of bathing habits, use of OTC moisturizers) this no longer is a non covered screening event but a reimbursable event.The level of CPT will vary based on your findings and Medical Decision Making.The medical necessity for a re-visit will depend on the above.

Podiatry, unlike internal medicine and family practice are able to get reimbursed for annual well exam, podiatry does not get reimbursed for an annual diabetic foot exam. The good news is that most insurance covers an illness, injury, or symptom related to E&M. A common diabetic issue is Type 2 diabetes with polyneuropathy, ICD-10-CM E11.42. They have a chronic illness that affects feet and legs and should be evaluated and medically managed when necessary.

ANSWER: My first recommendation is to know what CMS says, take a look at this link Foot care (routine) | Medicare If all the provider is doing is nail debridement, then they should be billing the nail CPT codes (11720 & 11721) regardless of traditional Medicare rules. If the MA plan has the policy they cover non medically necessary nail care, then if you perform that service, you should bill the most appropriate CPT coding that day.

Can you tell me what is best to do? ANSWER: If the podiatrists/provider reviewed the medical policy on the MA site and it is stated they do not pay, then it is not covered. If performing an E/M at the time then bill E/M. It is alright to create your own code for cosmetic nail care, practices do this and the patient pays. It is fine to call it a “medical pedicure service”, meaning you the medical provider are doing the cosmetic service and I would bet most plans do not cover cosmetic services. Again, each MA plan has rules, see what they say about cosmetic services.