Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare & Medicaid Services (CMS), has conducted post-payment review of claims for Medicare Part B Podiatry, billed on dates of service from January 1, 2020, through December 31, 2020. Below are the review results:

Background

Medicare Part B generally does not cover routine foot care services, such as the cutting or removal of corns and calluses or trimming, cutting, clipping or debridement of toenails. Part B may cover these services if they are performed as a necessary and integral part of covered services, for the treatment of warts on the foot, in the presence of a systemic condition or conditions, and for the treatment of infected toenails.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical record review on podiatric services. The SMRC performed medical record review on supporting documentation, to determine if podiatry services were medically necessary treatment of foot injuries, diseases or other medical conditions affecting the foot, ankle, or lower leg. The SMRC conducted medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

• Medical Necessity
  • The Social Security Act (SSA) Title XVIII, Section 1862(a)(1)(a), provides the guidance that:
    
    “No payment may be made under Part A or Part B for any expenses incurred for items or services which, are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
    
    Claims were denied when submitted documentation did not support the requirements in applicable Local Coverage Determination (LCD). Documentation did not contain medical records to support the presence of a systemic condition and/or abnormal signs or symptoms for podiatry services.
• Requested Records Not Received
  • CMS Internet-Only Manuals, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8, requires providers/suppliers to respond to requests for documentation within 45 calendar days of the additional documentation request. The documentation was not submitted or not submitted timely.
• Documentation Did Not Support the Modifiers Billed
  • CMS Internet-Only Manuals, Medicare Program Integrity Manual Chapter 3, IOM Pub 100-04, Medicare Claims Processing Manual Chapter 1, requires appropriate modifiers be appended to claims. Claims billed with the Q modifier were not supported within the submitted medical record documentation.

References

Social Security Act (SSA), Title XVIII

• § 1815(a) Payment to Providers of Services
• § 1833(e) Payment of Benefits
• § 1862(a)(1)(A) Exclusions from Coverage and Medicare as Secondary Payer
• § 1862(a)(13)(C) Exclusions – Routine foot care
• § 1862(a)(7) Exclusions – Routine physical examinations
• § 1879(a)(1) Limitation of liability

Title 42 of the Code of Federal Regulations (CFR)

• § 410.12 Medical and other health services: Basic conditions and limitations
• § 411.15(k)(1) Services excluded from coverage
• § 424.5(a)(6) Basic conditions
• § 482.24 Condition of participation: Medical record services

Internet-Only Manual (IOM) Medicare Benefit Policy Manual (MBPM) Pub. 100-02

• Ch. 15, § 290 Foot Care
• Ch. 16, § 20 Services Not Reasonable and Necessary
• Ch. 16, § 30 Foot Care

IOM, Medicare Claims Processing Manual, Publication 100-04

• Ch. 23, § 20.9 National Correct Coding Initiative (NCCI)

IOM, Medicare Program Integrity Manual (MPIM) Publication 100-08

• Ch. 3, § 3.2.3.2 Time Frames for Submission
• Ch. 3, § 3.3.2.4 Signature requirements
• Ch. 3, § 3.6.2.2 Reasonable and Necessary Criteria
• Ch. 3, § 3.3.2.5 Amendments, Corrections and Delayed Entries in Medical Documentation
• Ch. 3, § 3.2.3.8 No Response or Insufficient Response to Additional Documentation Requests
• Ch. 13, § 13.5.4 Reasonable and Necessary Provision in an LCD

CMS Coding Policies

• National Correct Coding Initiative (NCCI) Policy Manual, Effective January 1, 2020. Chapter 1: General Correct Coding Policies. Section E. Modifiers and Modifier Indicators. Section H. HCPCS/CPT Procedure Code Definition. Section J. “Separate Procedure” Definition. Chapter 3: Surgery: Integumentary System-CPT Codes 10000-19999. Section E. Lesion Removal.

Local Coverage Determination (LCD)

• L33833 Surgical Treatment of Nails
• L33922 Nail Debridement
• L33941 Routine Foot Care
• L34032 Debridement Services
• L34887 Surgical Treatment of Nails
• L35013 Debridement of Mycotic Nails
• L35138 Routine Foot Care
• L37643 Routine Foot Care

Local Coverage Article (LCA)

• A52996 Billing and Coding: Routine Foot Care
• A52998 Billing and Coding: Surgical Treatment of Nails
• A56232 Billing and Coding: Routine Foot Care
• A56640 Billing and Coding: Debridement of Mycotic Nails
• A56680 Billing and Coding: Routine Foot Care
• A57188 Billing and Coding: Routine Foot Care
• A57460 Billing and Coding: Treatment of Ulcers & Symptomatic Hyperkeratoses
• A57666 Billing and Coding: Surgical Debridement of Nails
• A57672 Billing and Coding: Nail Debridement
• A57759 Billing and Coding: Routine Foot Care
• A57954 Billing and Coding: Routine Foot Care
• A57957 Billing and Coding: Routine Foot Care

Other

• Medicare Learning Network (MLN) SSE1113 Foot Care Coverage Guidelines

Last Updated Aug 8, 2023