Podiatry Billing and Coding Guidelines

The medical field of podiatry focuses on the evaluation and care of patients with foot-related ailments. Conditions affecting the extremities, including the foot and ankle, are the focus of podiatric medicine. The study and treatment of foot conditions, both medical and surgical, as well as mechanical and physical, all fall under the purview of this subfield.

Many factors contribute to the difficulty of podiatry billing, from the need to establish and document the treatment’s medical necessity to the specifics of applicable coding. Additionally, Medicare covers a disproportionate share of the elderly, which means that billing and coding for podiatry services require extra work. Careful use of modifiers and familiarity with coding for inclusive procedures are also prerequisites.

Common Practices & Guidelines for Podiatry Medical Coding

Given that some of a Podiatrist’s services may not be covered by insurance, it’s important to verify coverage and establish medical necessity before submitting a claim. Improve your cash flow, operational efficiency, and quality of life for you and your patients with podiatry billing services.

The CPTs that are listed below are the ones that are used for the respective description:

76881:   Real-time ultrasound, nonvascular examination of the extremities, with image documentation

76882:   Real-time ultrasound with image documentation, focusing on the extremities and avoiding the blood vessels.

93922:   Physiologic studies of the upper or lower extremity arteries, performed non-invasively, at a single level, bilaterally

93926:   Performing a duplex scan on the arteries in the lower extremities or arterial bypass grafts

20552:   Injections, either single or multiple trigger points, either one or two muscles (s)

20553:   Injections, either single or multiple trigger points, into three or more muscles (s)

20605:   Aspiration, arthrocentesis, and/or injections

20610:   Arthrocentesis, aspiration, and/or injection

Overview of Podiatry Coding and Billing

In all types of podiatry offices across all states in the US, the most frequently used CPT codes are:

Coders and billers in the healthcare industry are having trouble with accurate coding and billing podiatry services. There is a consistent pattern of claims being denied, which leads to the suspension of services, the withholding of payments, and an overall climate of mistrust.

Incorrect procedure or diagnosis codes on a claim could be harmful to the patient. The wrong modifier can alter both the payment and the location of the procedure, which can have a significant impact on the payment.

Unexpectedly high patient bills may be the result of additional CPT codes. For this reason, accurate coding is critical for both patients and medical professionals.

Podiatry treats foot disorders, injuries, and abnormalities, including nails and skin. Podiatrists diagnose, treat, and operate on foot, ankle, and lower extremity problems. This specialty treats feet medically, surgically, mechanically, and physically.

Coding Podiatry Claims

Check the patient visit and documentation before coding. The medical record must contain all of them. Read the medical notes connected to the patient’s DOS (Date of Service) for accurate claim coding.

Podiatry CPT Codes That Are Frequently Used

These procedure codes describe podiatry services:

According to Medicare guidelines, at-risk foot care will be reimbursed only if services are provided at least 60 days apart.

11055, 11056, and 11057 – Corn and callus removal

In the absence of class findings, either “class findings” or painful ambulation are required for nail care. Class findings are required for all non-mycosis nail care.

Class findings are also required for callous care. However, PAIN is not a qualifier.

What exactly are class findings, and why are they important in podiatry coding?

Class findings are the coding criteria designed specifically for podiatry. On the basis of these criteria, you would receive confirmation of which of Q7, Q8, and Q9 should be used as a modifier.

Three Class findings exist:

Class A Results

non-traumatic amputation of the foot or an integral portion of the skeleton

Class B Findings:

• Absent posterior tibial pulse
• Absent dorsal pedal pulse
• Three of the advanced trophic changes listed below are required to satisfy a class B finding:
• Hair growth
• Pigmentary alterations
• Changes in the hue of the skin and nails
• Texture of the skin 

Class C Findings

• Claudication
• Adapting to Foot Temperature Changes
• Paresthesias Edema (abnormal spontaneous sensations in the feet, e.g., tingling)
• Burning

Using the Results of the Class, Which Modifier Should I Use?

When filing claims, Q modifiers specify the patient’s condition and related findings. Podiatry billing codes are Q7, Q8, and Q9.

Question 7 = One result of Class A

Question 8 = Two Grade B Results

Question 9 = Two results in the Class C range and one Class B result

Always use modifiers TA–T9 for toenails and F1–FA for fingernails when coding for procedures involving either nail type. Don’t ever write LT or RT to describe your left or right hand or foot.

Left and right LT and RT modifiers are only valid for left and right foot surgery, and not for fingers or toes.

Exactly what does LCD stand for?

Local coverage determination (LCD) serves the same function. In the United States, the LCD governing a given field of expertise varies by state.

LCD’s Crucial Role in the Future

Accurately billing a claim relies heavily on LCD. Picking the right Diagnosis code (Primary and Secondary Dx) and the most appropriate CPT code is the most important task for a coder.

CMS.gov’s LCD is the single most important resource for determining whether a service is medically necessary.

As a matter of Medical Necessity,

The coder needs to be competent in applying the appropriate CPTs and diagnosis codes. CMS.gov makes NCD (National coverage determinations) and LCD (Local coverage determinations) that must be used to validate the codes.

The medical necessity of the services and treatment billed for must also be documented through coding in order to be re-appealed for appropriate reimbursements.

Important: Medicare should not be billed for services that are not covered (not included in LCD) even if the billing indicates that they are. Use the correct modifier when submitting claims to Medicare for services not covered by that program.

In order for primary foot care to be considered a covered service, the patient must have one or more diseases that Support Medical Necessity according to the LCD section for foot care.

If it doesn’t, use the GY modifier (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) to indicate that it’s not covered by Medicare.

CPT codes 11721, 11046, 11042, etc., are commonly used to describe services involving evaluation and management. For this reason, you must add a modifier to the E&M CPT code 99204 or 99213 whenever you submit a claim for these services.

Guidelines for Precise Coding:

Codes 11055, 11056, 11057, 11719, 11720, 11721, and G0127, which refer to common foot care procedures, will be governed by international standards for surgery. So, if a patient receives both routine foot care and an E&M service on the same day, only the E&M service that can be clearly distinguished from the foot care service, as indicated by the use of modifier 25, and supported by medical records, will be reimbursed.

When it comes to podiatry medical billing and coding, you might have to provide more information and medical necessity paperwork to your insurance companies than you would in general medicine.

You don’t have to be an expert on every procedure and HCPCS code in existence or have memorized the entire ICD-9 manual of diagnoses.

Podiatry billing, like other specialties, has its own set of rules to follow, but these rules are straightforward and can be learned quickly.

Furthermore, many specialized fields pay more because of the unique requirements for submitting and following up on claims. Enabling 40+ healthcare specialties across the US, outsourcing medical billing helps to optimize reimbursements with end-to-end revenue cycle management. We offer medical billing services to medical practices, hospitals, laboratories, and independent and group practices.