01-050 Podiatry Notification of Medical Review

Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Medicare Part B Podiatry billed on dates of service from January 1, 2020, through December 31, 2020. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers and suppliers may wish to consult when submitting claims.

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/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 will perform 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 will conduct medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

CPT Codes Description
11055 Trim skin lesion
11056 Trim skin lesions 2 to 4
11057 Trim skin lesions over 4
11719 Trim nail(s) any number
11720 Debride nail 1-5
11721 Debride nail 6 or more
G0127 Trim nail(s)

Access related project details below.

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.

Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.

  1. Operative/procedure report
  2. Paring or cutting procedures on the skin
  3. Practitioner, nurse, and ancillary progress notes
  4. Documentation to support a systemic condition, neuropathy, vascular impairment, onychogryphosis and/or onychauxis
  5. Evaluation of foot structure, vascular and skin integrity
  6. Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
  7. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  8. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
  9. Any other supporting documentation
  10. If medical record documentation is submitted via esMD: Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
  11. PLEASE NOTE: It is the responsibility of the supplier or provider to obtain all documentation from the ordering or referring provider to ensure medical necessity criteria have been met

References/Resources

Title XVIII of the Social Security Act (SSA)

  • 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

National Correct Coding Initiative (NCCI) Policy Manual

  • 1 § E Modifiers and Modifier Indicators
  • 1 § H HCPCS/CPT Procedure Code Definition
  • 1 § J CPT “Separate Procedure” Definition
  • 3 § E Lesion Removal

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

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

IOM, Medicare Claims Processing Manual, Publication 100-04

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

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

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

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 Jul 14, 2022