Medically necessary treatment for foot, ankle or lower leg conditions such as injury or disease is covered by Medicare if provided by a podiatrist or physician. Generally, routine foot care that is not medically necessary will not be covered.

However, there are wide variations on exactly what is covered. Local Coverage Determination (LCD) policy, as determined by a Medicare Administrative Contractor (MAC), will decide whether a particular service is reasonable and necessary. LCD guidelines are developed in the absence of a national coverage determination or when the specific region feels that there is a need for further definition.

Insurance carriers may also have specific coverage determination policies in place.

Medicare Podiatry Billing – Adhere to LCD Codes

Your regional LCD will catalog which diagnostic ICD-10 codes may be paid for a specific CPT code. However, there cannot be an ICD-10 code for every possible situation. 

Sometimes the ICD-10 codes overlap; in this scenario, when billing you must choose between two codes that are similar. However, the LCD may contain only one of the two so you must be able to make the right choice. One tool that may help is when you receive a Medicare explanation of benefits (EOMB). There may be a reference to an LCD that may have been updated. 

The LCD has other information that is essential for accurate claims billing. For example, the LCD may indicate:

· How often routine foot care is allowed

· The frequency that a service is allowed in a certain time period

· Which additional ICD-10 codes are required as secondary codes

· Which products are appropriate for certain types of wounds and if conservative care is first required

LCD billing information helps you to get paid for your services because bills are properly coded. It is in your practice’s best interest to use billing information that is as accurate as possible and, when errors occur and are noted, to update your process for future similar scenarios.

More Resources

CMS MLN Matters describing Medicare Podiatry Services

CMS list of MAC jurisdictions

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