Basic Podiatry Billing - Rules and Tips
An explanation of the basics and special needs of podiatry billing...
For every medical specialization, there is an equal specialization in the medical coding and billing guidelines, regulations, and techniques needed for that specific type of medicine. Podiatry is no different, since it also requires a special set of medical coding and billing techniques.
Podiatry is the medical specialty concerned with the diagnosis and treatment of diseases, injuries, and defects of the human foot.
This specialty includes medical, surgical, mechanical, and physical treatments of the foot. As such, podiatrist billers are responsible for coding all of these treatments.
Podiatrist services
Podiatrists treat a very specialized set of symptoms, diseases, and conditions.
Some of these treatments are for routine care, whereas others are related to underlying issues, such as metabolic, neurologic or peripheral vascular disease, injury, ulcers, wounds, and infections.
CMS, (Centers for Medicare and Medicaid Services), defines many of the regulations regarding what may or may not be covered services under insurance.
Although CMS doesn't directly inform insurance agencies what types of service they may or may not pay for, they do hold sway when it comes to podiatry billing and coding guidelines.
According to CMS, the only covered podiatry services are those considered medically necessary and reasonable foot care. This means that any elective or non-medically necessary services might not be covered as reasonable foot care - insurance won't pay for it!
If the podiatry service is for routine care, it must be considered either Additional, Mandatory, Supplemental, or Optional Supplemental benefits.
Other services, like the treatment of warts, is covered as it would be as if the warts were located on any other site on the body (rather than as a specialized podiatric service).
Exclusions to covered podiatry services
Certain foot care services aren't covered by Medicare, and may or may not be covered under general third-party insurance.
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:
Routine Foot Care - Some exclusions 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)
Flat foot - No exceptions
Subluxation of the Foot - There are only 2 exceptions to this denial:
- that the subluxation (or dislocation) was of the ankle joint
- or for care that has resulted from the subluxation of structures within the foot.
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.
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.
Other specifically covered services
Medicare specifically covers other podiatry services:
- Foot care for patients with chronic disease
- Treatments for wound care
- Hyperbaric oxygen therapy for hypoxic wounds and diabetic wounds of the lower extremities
Just a glance at both of the lists above gives you an insight into how particular the world of specialty billing can be.
Each one of these specially covered services includes strict billing and coding regulations, as well as the number of times a patient can be treated, in what setting, and with what diagnosis.
Additional Podiatry Billing Guidelines
As well as the typical medical coding and billing guidelines, there are other special billing guidelines for podiatry services:
Claims involving complicated conditions - These have 2 special requirements:
- They must document the name of the physician who diagnosed the complicating condition on the first submission of the claim.
- 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.
Wow, that's pretty specific!
Yes, the world of specialty billing is very specific, but fittingly so. If you're new to the world of billing and coding, don't let all of these crazy guidelines and regulations dissuade you.
In podiatry billing, you may be subject to more scrutiny, and have to provide your insurance companies with more information and medical necessity paperwork that if you were in general medicine.
But you also don't have to learn the entire ICD-9 diagnosis book, as well as understand the wide range of procedure and HCPCS codes.
Specialty billing, including podiatry billing, may have a specific set of rules to follow, but they are so few that they are easy to learn, easy to follow, and generally result in an understandable work flow of requirements and guidelines.
Furthermore, many specialty fields offer higher rates of pay because of the highly specialized ways you have to submit and follow up on claims. See: medical billing and coding jobs.
No matter which medical field you go into in the health care industry, you'll be subject to rules, regulations, and strict guidelines - it's simply part of the job of a medical biller and coder.
Podiatry billing is no different.
Explore the basics of billing other specialties on our Billing Tutorials page.
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