Exclusions to covered podiatry services:

If you’re billing for podiatry services, and they fall into these categories, you may be fighting a hopeless battle against your insurance company. They are, with certain exceptions noted:

1. Routine Foot Care– Some exclusion to the outright denial of routine foot care services include:

• initial care, for a service that may result in a covered diagnosis
• the presence of a metabolic, neurologic, or peripheral vascular disease
• Mycotic nails
• or if the patient is under the care of a primary care physician for diabetes mellitus, chronic thrombophlebitis, or peripheral neuropathies (such as carcinoma, malnutrition, or multiple sclerosis)

2. Flat foot – No exceptions
3. Subluxation of the Foot– There are only 2 exceptions to this denial:

• The Subluxation (or dislocation) was of the ankle joint
• For care that has resulted from the Subluxation of structures within the foot.

4. Supportive Devices of the Foot– Exceptions include orthotic shoes that are an integral part of a leg brace, or therapeutic shoes for those with diabetes.
5. Therapeutic Shoes for Individuals with Diabetes– There is 1 exception to this denial, and it includes a narrow permit of special shoes and inserts for persons with diabetes.

Podiatry billing Guidance:

• Claims involving complicated conditions – These have 2 special requirements:

• 1. They must document the name of the physician who diagnosed the complicating condition on the first submission of the claim.
  2. They must also carefully document the severity of the diagnosis, not just the diagnosis itself.

• The nature of the service determines the exclusion of foot care, rather than the provider who performs the service. This means that if a primary care physician performs a non-covered service, they won’t be reimbursed just because they aren’t a podiatrist.
• Some payments are made on the basis of being integral to a covered procedure, whether or not the incidental service is excluded. These are regarded as incident to services.

LCD Policies:

The LCD also gives the information that how frequent services such as routine foot care is allowed or how many times a service is allowed within a given period of time. Also, an LCD may provide you information to other ICD-10 codes that may be required as a secondary code for payment. Certain products, such as wound care products, are only indicated for certain types of wounds. The LCD may offer information for that as well.

25 Modifiers:

The -25 modifier is the most audited modifier. Use this modifier when the E/M service is “significant and separately identifiable” from the procedure you are performing on the same day. It is not proper to bill an E/M service every time provider performs a procedure as some sort of a baseline office fee.

RT/LT vs. 50 Modifiers:

There is no rhyme or reason as to when to use the RT/LT modifiers versus the -50 modifier. However, the best course of action is to check the Correct Coding Initiative edits, which are available at the Centres for Medicare and Medicaid Services (CMS) website or in a podiatry-focused resource such as the American Podiatric Medical Association (APMA) Coding Resource Centre. This will tell you whether that specific CPT code requires a single line billed with the -50 modifier or if you need to bill two separate lines with the RT and LT modifier.

51 Modifiers

As a rule, do not use the -51 modifier especially for Medicare claims. This seems to kick out claims automatically. The -51 modifier simply states that multiple procedures are happening at the same visit.

T codes and TA Modifiers:

Use T codes to differentiate billing for separate digits. T codes are digital codes and are for services distal to the metatarsophalangeal joint. Accordingly, do not use a TA modifier when performing a bunion surgery. Use T codes to separate surgery performed on multiple toes. If you only operate on a single toe, then there is no need to use a T modifier.