Effective coding management for Podiatry Practices in 2020

 Erika Regulsky Tags: , , , , Billing & Collections, CFO's Corner, EHR Implementation, Most Recent

Social Shares


Effective podiatry coding management in 2020

Podiatrists may have to deal with diverse foot conditions – chronic or acute. Not all services are reimbursable. Most services related to the foot are based on medical necessity requirements, and this makes podiatry coding rather complex.

Accurate medical coding is an important requirement for clean claim submission. More specific ICD-10, CPT and HCPCS codes should be used to report diagnosis and treatment provided to prevent claim denials and ensure appropriate reimbursement. Incorrect coding will impact your practice’s revenue. Certain multiple procedure codes can be listed for one operative note, while some of them may be considered as part of the more complex procedures being performed. Based on specific payer requirements, separate procedure codes can also be billed with other codes. Careful review of all the codes in this range is recommended before choosing the final code for any podiatry procedure. Medical coders should also be up to date with the changing coding standards in podiatry specialty.

Modifiers provide additional information to payers to make sure the provider is paid correctly for services rendered. If appropriate, more than one modifier may be used with a single procedure code; however, they are not applicable for every category of the CPT codes. Some modifiers can only be used with a particular category and some are not compatible with others. 

Given below are some general coding guidelines to be followed:

  • CPT code 11721 (Covered Nail Debridement 6 or more) requires Q8 modifier (for routine check-up) with systemic conditions which is medically necessary to be reimbursed by Medicare but only six times in a year.
  • Podiatry modifiers include T1 to T9 modifiers (Toe modifiers) except for CPT code 97598, 11720 and 11721, in which case use of this modifier will result in denials.
  • HCPCS code J3301, J1100 (injection procedures) are used frequently in Podiatry Billing also providing significant amount of revenue to providers
    76881 for ultrasound, extremity, nonvascular, real-time with image documentation.
  • 76882 for limited ultrasound, extremity, non-vascular, real time with image documentation.
  • 93922 for non-invasive physiologic studies of upper or lower extremity arteries, single level, bilateral.
  • 93926 for duplex scan of lower extremity arteries or arterial bypass grafts.
  • 20552 for injections(s), single to multiple trigger point(s) one or two muscle(s).
  • 20553 for injections(s), single to multiple trigger point(s) three or more muscle(s).
  • 20605 for arthrocentesis, aspiration and/or injections.
  • 20610 for arthrocentesis, aspiration and/or injection.

Routine foot care is normally excluded from Medicare coverage except for the following conditions or situations:

Necessary and integral part of otherwise covered services

Diagnosis and treatment of ulcers, wounds or infections
Trimming or cutting nails to be fitted with a cast following a fracture (if the cast is separately billable service)

Presence of systemic conditions

Metabolic, neurologic or vascular conditions that may require scrupulous foot care by a professional

Treatment of warts on foot

Treatment of warts, including plantar warts, on the foot is covered to the same extent as services provided for treatment of warts located elsewhere on the body.

Mycotic nails

In the absence of a systemic condition, treatment of mycotic nails may be covered,  only when the following ccriteria are met:

Ambulatory patient

Clinical evidence of mycosis of toenail and Patient has marked limitation of ambulation, pain or secondary infection resulting from thickening and dystrophy of the infected toenail plate

Non-ambulatory patient

Clinical evidence of mycosis of the toenail and Patient suffers from pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.


Q” modifiers (Q7, Q8 and Q9) are utilized to denote class A (Q7), Class B (Q8) and Class C (Q9) findings. These modifiers may be used with procedure codes 11055, 11056, 11057, 11719, 11720, 11721 or G0127.

Submitting claims using Q modifiers indicate the findings related to the patient`s condition. However, the provider is still responsible for documenting the finding in the patient`s record. Failure to provide documentation supporting the use of Q modifiers on any claim may result in denial for that claim.

Hyperkeratotic lesions criteria

Procedure C ode 11055, 11056, or 11057 will be included in the Medicare covered foot care service code (8101) when billed with a diagnosis from the diagnosis list pertaining to hyperkeratotic lesions coding criteria.

Nondystrophic Nails Coding Criteria

Procedure Code 11719 will be included in the Medicare covered foot care service code (8101) when billed with a diagnosis from the diagnosis list pertaining to nondystrophic nails coding criteria.

Debridement of Nail Coding Criteria

Procedure Code 11720 or 11721 will be included in the Medicare covered foot care service code (8101) when billed with a diagnosis from the diagnosis list pertaining to debridement of nail coding criteria.

Billing for Podiatric Surgical Procedure

For podiatric surgical procedures, including diagnostic surgical procedures, providers cannot fragment and bill separately. Generally, such procedures are included in the major procedure. Procedures in this category include, but are not limited to, the following:

  • Arthroscopy or arthrotomy procedures in the same area as a major joint procedure, unless the claim documents a second incision was made.
  • Local anaesthesia administered to perform the surgical or diagnostic procedure.
  • Scope procedures used for the surgical procedure approach.

Laboratory and X-Ray Services

  • Cultures for foot infections and mycotic (fungal) nails for diagnostic purposes.
  • Sensitivity studies for treatment of infection processes.
  • Medically necessary pre surgical testing.

Doppler Evaluations

Ultrasonic measurement of blood flow (Doppler evaluation), subject to the Following limitations:
The ultrasonic measurement is for preoperative podiatric evaluation.

  • The measurement cannot be used for routine screening
  • The measurement cannot be used as an evaluation of routine foot care procedures, including such services as removal or trimming of corns, calluses, and nails

Prior authorization has been obtained for the proposed medical procedure.

  • A preoperative diagnosis of diabetes mellitus, peripheral vascular disease, or peripheral neuropathy has been made.
  • The preoperative Doppler evaluation is limited to one per year

Orthopaedic or Therapeutic Footwear

With a physician’s written order, IHCP covers the following items for members of all ages

  • Corrective features built into shoes, such as heels, lifts, wedges, arch supports, and inserts
  • Orthopaedic footwear, such as shoes, boots, and sandals
  • Orthopaedic shoe additions

Prior authorization is required when a podiatrist prescribes or supplies corrective features built into shoes – such as heels, lifts, wedges, arch supports, and inserts

Community Health Worker Services

For dates of service on or after July 1, 2018, the IHCP covers community health worker (CHW) services when the CHW meets certification requirements, is employed by an IHCP-enrolled billing provider, and renders the service under the supervision of a qualifying IHCP-enrolled provider type, which includes podiatrists. The supervising provider’s NPI should be indicated as the rendering provider on the claim. The CHW’s name must be included in the claim notes
The following procedure codes are covered for billing CHW services:

  • 98960 –Self-management education & training, face-to-face, 1 patient
  • 98961 –Self-management education & training, face-to-face, 2–4 patients
  • 98962 –Self-management education & training, face-to-face, 5–8 patients

Reimbursement for CHW services to 4 units (2 hours) per day and 24 units (12 hours) per month per member.
Services provided by a CHW are reimbursed at 50% of the resource-based relative value scale (RBRVS) amount.

Providers should use designated “diabetics only” HCPCS codes to bill for therapeutic shoes, as well as modifications and inserts, when provided to members with severe diabetic foot disease.
Members are eligible for a total of three pairs of inserts each calendar year. Custom-moulded shoe codes include the insert. Therefore, the IHCP allows for either of the following:

  • One pair of custom-moulded shoes and two additional pairs of inserts
  • One pair of depth-inlay shoes and three pairs of inserts

A5512 has a maximum unit of six per date of service. A5513 has a maximum unit of two per date of service. If the provider dispenses inserts independently of diabetic shoes, the member must have appropriate footwear into which to place the insert

For each code, one unit equals one shoe or insert. If a member needs a pair of shoes or inserts, providers should submit the claim using the appropriate HCPCS code with “2” as the unit of service.

Social Shares

I’m a multi-certified revenue cycle management professional and compliance officer with 20+ years of experience. I contribute articles to leading healthcare publications and journals. I am currently working as Senior Transition Manager, in BillingParadise headquartered at Diamond bar, California. BillingParadise offers Medical Billing Services that intersect perfectly with the EMR/Practice management system you use.BillingParadise has offices in New Jersey, New York, Florida, Georgia, Minnesota, and Texas.

Related Articles

Get paid Three times faster with our 24/7 medical billing services.

Work with medical billers who understand your EHR's billing process backwards and forwards

Avail Free RCM Audit Worth $2,000! Check out 19 different KPI reports that stops your cash flow.