Medicaid was established to provide health insurance for low-income people. The program is funded by both the federal and state governments based on a formula (Federal Medical Assistance Percentages) that varies by state. Based on federal guidelines, all state Medicaid programs are required to provide more than 15 specific services as covered benefits.
Podiatric care is one of the optional covered benefits that states provide to varying degrees. Optional Medicaid-covered podiatric services generally include nail debridement, corn or callus removal, treatment of onychomycosis, and preventive services.
This guide breaks down everything you need to know. We’ll cover what Medicare pays for and what it doesn’t. You’ll learn how to bill the first time correctly. By the end, you’ll feel confident handling Medicare claims.
Understanding Medicare Coverage for Foot Care
Medicare divides foot care into two main groups. Some services get covered easily. Others face strict limits. Knowing the difference saves time and hassle.
What Medicare Covers
Medicare Part B covers routine foot care only in certain cases. The patient must have a medical condition that affects their feet. Common conditions include diabetes, peripheral arterial disease, and severe arthritis.
For patients with these conditions, Medicare pays for:
- Trimming thick nails
- Removing corns and calluses
- Basic foot hygiene care
- Debridement services
The keyword here is medical necessity. Every service must tie back to a qualifying condition. You cannot bill for cosmetic care or general comfort.
Services That Get Full Coverage
Some foot procedures receive coverage regardless of other conditions. These include:
Surgical Procedures
 Any medically needed surgery on the foot gets covered. This includes bunion removal, hammer toe correction, and fracture treatment.
Wound Care
Open sores, ulcers, and infected areas qualify for treatment. Medicare recognizes these as serious medical issues.
Fungal Infections
Severe cases of fungal nails may qualify. The infection must cause pain or risk of secondary infection.
Warts
Painful warts that limit walking get covered. Simple cosmetic removal does not qualify.
What Medicare Does Not Cover
Medicare denies payment for several common services:
- Routine nail trimming for healthy patients
- Callus removal without underlying disease
- Arch supports or custom orthotics
- Comfort shoes or modifications
- Preventive care for low-risk patients
These services can still be provided. However, the patient pays out of pocket. Make sure to inform them before treatment begins.
Key Billing Codes for Podiatry Services
Using the right codes ensures proper payment. Each service has specific codes. Mixing them up leads to denials.
Routine Foot Care Codes
The main codes for routine care are:
11055: Paring or cutting of single corn or callusÂ
11056: Paring of two to four lesionsÂ
11057: Paring of more than four lesions
These codes require careful documentation. You must prove medical necessity for each claim.
11719: Trimming of one to five nailsÂ
11720: Debridement of six to ten nailsÂ
11721: Debridement of more than ten nails, with extensive thickness
Nail trimming codes need supporting diagnosis codes. Link them to diabetes or vascular disease for the best results.
Surgical Procedure Codes
Common surgical codes include:
28285: Correction of hammer toeÂ
28296: Bunionectomy with metatarsal osteotomyÂ
28290: Simple bunion correctionÂ
28308: Osteotomy for foot reconstruction
Surgical codes generally process smoothly. They rarely face the same scrutiny as routine care codes.
Wound Care and Debridement
Active wound treatment uses these codes:
97597: Removal of dead tissue, first 20 square centimetersÂ
97598: Each additional 20 square centimeters
11042: Debridement to subcutaneous tissueÂ
11043: Debridement to muscle or fasciaÂ
11044: Debridement to bone
Document wound size, depth, and appearance. Take photos when possible. This creates a clear record of medical necessity.
Required Documentation for Claims
Good records make or break your claims. Medicare auditors review documentation closely. Missing details cause denials.
Patient History Requirements
Every chart must include:
Chief Complaint: Why did the patient come in today? Use their own words when possible.
History of Present Illness: How long has the problem existed? What makes it better or worse? Has the patient tried any treatments?
Past Medical History: List all relevant conditions. Include diabetes, heart disease, and circulation problems.
Current Medications: Write down every drug the patient takes. This shows you considered drug interactions.
Social History: Note smoking status, alcohol use, and activity level. These factors affect healing and treatment choices.
Physical Exam Documentation
Your exam notes should describe:
General Appearance: Are the feet clean? Is there swelling or redness?
Skin Condition: Check for dryness, cracks, or color changes. Note any wounds or lesions.
Nail Assessment: Describe thickness, color, and shape. Look for fungal infection or ingrown edges.
Vascular Status: Check pulses in the feet. Note any signs of poor circulation.
Neurological Findings: Test sensation with monofilament. Check reflexes if appropriate.
Treatment Notes
Record exactly what you did during the visit:
- Which nails were trimmed
- Where calluses were removed
- What wounds were treated
- Which medications were prescribed
- What education was provided
Use specific measurements. Instead of “large callus,” write “3-centimeter callus on left plantar heel.”
Medical Necessity and Class Findings
Medicare uses a class system for routine foot care. Understanding these classes is critical.
Class A Findings
These patients qualify for routine foot care coverage:
Diabetic Neuropathy: Loss of feeling in the feet creates a high risk. Even small injuries can become serious.
Peripheral Arterial Disease: Poor blood flow slows healing. Minor problems escalate quickly.
Diabetic Retinopathy: Vision loss prevents self-care. Patients cannot safely trim their own nails.
Document these findings clearly. Use specific tests and exam results. Vague statements don’t hold up under review.
Class B Findings
These conditions also qualify, but need stronger documentation:
Severe Arthritis: Must limit the patient’s ability to bend or reach their feet.
Advanced Age with Weakness: The patient must be unable to safely perform self-care.
Document functional limitations. Explain why the patient cannot care for their own feet.
Class C Findings
Patients without qualifying conditions fall into Class C. They do not qualify for covered routine care. You can still treat them, but they must pay privately.
Always inform patients of their coverage status. Get written consent before providing non-covered services. This protects both of you.
Proper Use of Modifiers
Modifiers tell Medicare important details about your service. They affect payment amounts and approval rates.
Common Modifiers in Podiatry
Modifier Q7: Used for routine foot care when one Class A finding exists. This modifier is essential for diabetic patients.
Modifier Q8: Applied when two Class A findings are present. Payment may be higher with this modifier.
Modifier Q9: Used for three or more Class A findings. This shows the highest level of medical necessity.
Modifier GY: Indicates a service that Medicare never covers. Use this for truly non-covered care. It protects you during audits.
Modifier GA: Shows the patient signed an Advance Beneficiary Notice. They agreed to pay if Medicare denies the claim.
When to Use Each Modifier
Choose modifiers based on documentation:
If the patient has diabetes with neuropathy, use Q7. This links routine care to a covered condition. For a diabetic patient who also has poor circulation, use Q8. Multiple conditions increase medical necessity. When providing comfort care to a healthy patient, use GY. This clearly marks the service as non-covered.
Billing for Diabetic Shoe Programs
Medicare covers special shoes for diabetic patients. However, the rules are very specific.
Qualification Requirements
Patients must have all of these:
- Diabetes diagnosis
- One or more specific foot conditions
- Doctor’s certification of medical necessity
- Prescription from the treating physician
The foot conditions that qualify include:
- Previous foot ulceration
- History of partial foot amputation
- Current foot ulcer
- Previous callus formation with ulcer history
- Foot deformity
- Poor circulation with evidence of callus formation
Frequency Limitations and Timing
Medicare limits how often certain services can be billed. Exceeding these limits triggers denials.
Routine Foot Care Frequency
Medicare typically covers routine care every 61 days. This applies to patients with qualifying conditions.
You can bill more frequently with extra documentation. Show why the patient needs more frequent care. Examples include:
- Active wound requiring weekly treatment
- Rapid nail growth is causing pain between visits
- Severe neuropathy with high risk of injury
Without special circumstances, stick to the 61-day rule. It keeps your claims clean and reduces audit risk.
Diabetic Shoe Timing
Custom shoes are limited to one pair per calendar year. The year runs from January to December, not from the date of service. Inserts are limited to three pairs per year. Some patients need replacements sooner due to wear. Document the medical reason for early replacement.
Wound Care Frequency
Active wound debridement has no set frequency limit. You can bill for each medically necessary treatment. However, document progress at each visit. Show that treatment is working. If a wound isn’t healing, explain why continued debridement is still appropriate.
Common Billing Errors and How to Avoid Them
Most claim denials stem from preventable mistakes. Learning these common errors saves time and money.
Missing or Incorrect Diagnosis Codes
Every service needs a diagnosis code. The code must support medical necessity for that service.
Common mistake: Using a general diabetes code for routine foot care. Medicare needs more specific codes showing complications.
Solution: Use codes that indicate diabetic neuropathy, peripheral arterial disease, or other qualifying conditions.
Insufficient Documentation
Vague notes lead to denials. Auditors need clear evidence of what was done and why.
Common mistake: Writing “trimmed nails” without other details.
Solution: Specify which nails, why trimming was needed, and what qualifying conditions are present.
Wrong Code Selection
Using incorrect procedure codes confuses the claim.
Common mistake: Billing debridement codes for simple nail trimming.
Solution: Match the code to the actual work performed. Don’t upcode to increase payment.
Modifier Errors
Missing or wrong modifiers cause processing problems.
Common mistake: Forgetting Q7, Q8, or Q9 modifiers on routine care claims.
Solution: Always check which modifiers apply before submitting claims.
Timing Issues
Billing too frequently triggers automatic denials.
Common mistake: Submitting routine care claims less than 61 days apart without explanation.
Solution: Track visit dates carefully. Include extra documentation when frequent visits are needed.
Preventing Future Denials
Learn from each denial. Look for patterns in your rejected claims.
If multiple claims are denied for insufficient documentation, improve your note templates. Add prompts for key details. If frequency limits cause problems, set up reminder systems. Track when each patient is eligible for their next covered visit. Share denial information with your billing staff. Everyone should understand what Medicare requires.
Conclusion
Medicare podiatry billing requires attention to detail and ongoing education. The rules may seem complex at first. However, breaking them into manageable pieces makes the process much easier. Focus on documentation above all else. Clear, complete records support every claim you submit. They prove medical necessity and justify your services. Stay current with policy changes. Medicare updates its rules regularly. What worked last year may not work today. Use available resources. Your MAC, professional associations, and billing software all offer help. Don’t hesitate to ask questions when uncertain.
Your patients depend on the foot care you provide. Proper billing ensures Medicare compensates you fairly for that care. When billing works smoothly, you can focus on what matters most, helping people stay healthy and mobile. Contact Connecticut Medical Billing today to learn how their podiatry billing services can help your practice thrive. Let the experts handle the paperwork while you focus on treating patients.
FAQs
How many podiatry visits does Medicare cover?
Medicare will help cover 1 foot exam per year if you have diabetes‑related lower leg nerve damage that can increase the risk of limb loss.
What is the 3-day rule for Medicare billing?
Medicare’s 3-Day Payment Window Rule (or 72-Hour Rule) requires hospitals to bundle certain outpatient diagnostic and related non-diagnostic services provided in the three days before an inpatient admission onto the main inpatient claim.
What are the 5 things Medicare does not cover?
Medicare generally doesn’t cover long-term care, most dental care, routine vision & hearing care (like exams, glasses, hearing aids), cosmetic surgery, and most prescription drugs.
Can seniors get their toenails cut for free?
For free or low-cost senior toenail cutting, check with your local Area Agency on Aging for clinics, look for community health events (like those sometimes offered by Blue Cross), utilize home health aide services, or inquire with local senior centers for mobile clinics or volunteer programs.