Medicare Coverage of Podiatric Foot Care
There are approximately 11,000 licensed podiatrists, or Doctors of Podiatric Medicine (DPM), in the United States. Medicare classifies them as physicians who can receive Part B payments for providing care limited to the diagnosis and treatment of conditions of the foot and ankle. Podiatrists use noninvasive medical and surgical procedures to treat conditions such as corns, bunions, plantar warts, fungal infections, subluxations, sports injuries, and diabetic ulcers. They also trim toenails. In the course of a year, more Medicare beneficiaries visit podiatrists than chiropractors and psychiatrists combined. More than 6 million beneficiaries received Medicare-covered podiatry services in 2012, with approved payment amounts totaling more than $2 billion.
Medicare agrees to cover any foot care services that are reasonable and medically necessary. These conditions include:
- Diabetes mellitus
- Arteriosclerosis obliterans
- Buerger’s disease
- Chronic thrombophlebitis
- Peripheral neuropathies involving the feet
- Malabsorption / Celiac Disease
- Pernicious anemia
- Multiple Sclerosis
- Chronic Renal Disease
- Traumatic Injury
- Leprosy / Neurosyphilis
- Hereditary Disorders
Medicare may also cover the treatment of plantar warts, mycotic nails, infected toenail plates and secondary foot infections. They will also cover hammer toes, bunion deformities, and heel spurs.
Medicare Part B covers medically necessary care for treatment of injury, disease, or other medical conditions affecting the foot, ankle, or lower leg. It covers this treatment if provided by a physician (M.D.) or a Medicare-certified podiatrist (doctor of podiatric medicine, or DPM). This can include treatment for chronic conditions, such as bunion deformities and heel or toe spurs. Medicare Part B doesn't cover routine foot care that's not medically necessary.
Foot examinations for people with diabetes and therapeutic shoes and inserts for people with diabetes-related foot conditions are covered differently by Medicare Part B.
What about long-term, chronic foot care treatments?
Medicare will cover checkups every six months for beneficiaries with a documented diagnosis or sensory neuropathy and loss of protective sensation - notably found in diabetics. Electrostimulation therapy for wound healing is covered for chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers, as long as certain conditions are met. Hyperbaric Oxygen Therapy for hypoxic and diabetic wounds of the lower extremities is also covered in patients with Type I or Type II Diabetes who have wounds of Wagner grade III or higher and failed to see any measurable results from standard wound therapy after 30 days. Coverage for custom-molded therapeutic shoes and inserts for diabetics is also available.
Generally speaking, HYPERLINK "http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedicarePodiatryServicesSE_FactSheet.pdf" \t "_blank" Medicare DOES NOT cover:
- Treatment of flat foot – Flat foot is when one or more of the foot’s arches have flattened out, causing discomfort. Supportive devices are not covered.
- Routine foot care – Removal of corns and calluses, toenail cutting / nail debridement, cleaning, soaking, applying cream, and other hygienic or preventative maintenance care is not covered UNLESS you fall into a certain category.
- Supportive devices – Medicare usually does not cover orthopedic shoes or custom orthotics, unless it is part of a leg brace. There are, however, exceptions to this rule.
One of the main sources of confusion about Medicare’s foot care benefit is the “routine foot care exclusion.” In practice, Medicare covers routine foot care for beneficiaries with certain serious health conditions, such as the presence of a systemic condition like diabetes.
The Medicare Benefit Policy Manual describes the following services as routine and not covered:
- Cutting or removing corns and calluses
- Trimming, cutting, and clipping nails
- Other hygienic and preventive maintenance care such as cleaning and soaking, or the use of skin creams to maintain skin tone
- Any other service performed in the absence of localized illness, injury, or symptoms involving the foot
Medicare also excludes coverage treatment of flat feet, and it generally doesn’t pay for arch supports, other supportive devices for the feet, and orthopedic shoes. The exceptions are for a shoe that “is an integral part of a leg brace” and therapeutic shoes for people with diabetes. Medicare also doesn’t pay to treat subluxated structures of the foot defined as partial dislocations or displacements of joint surfaces, tendons, ligaments, or muscles. But it does cover treatments for subluxations in the ankle joint and treatment for partial joint displacements in the foot caused by conditions like osteoarthritis.
In some cases, Medicare covers routine foot care services if they comprise “a necessary and integral part” of other covered services such as treatment of ulcers, wounds, or infections. Medicare covers treatment of warts on the feet, including plantar warts, “to the same extent as services provided for the treatment of warts located elsewhere on the body.” Medicare covers the treatment and removal of symptomatic warts.
Medicare also covers Mycosis; a communicable fungal infection that often causes discoloration and thickening of the toenails. Serious infections may cause the toenail to separate from the nail bed and cause pain and difficulty walking. Medicare does cover the treatment of mycotic toenails in the absence of a systemic condition like diabetes or peripheral neuropathy but only when the clinical record contains evidence of the presence of mycosis in the nail and the patient experiences pain or difficulty walking or develops a secondary infection in the toenail plate. Usually, though, Medicare will likely view the treatment of mild fungal infections as routine foot care. In more severe cases, Medicare covers the debridement of mycotic toenails – a cutting or grinding procedure used to thin degenerating toenails and alleviate pain.
Medicare Beneficiaries with a systemic condition that decreases circulation or sensation in the legs and feet may require podiatry services that otherwise would be considered routine. Thus, Medicare will pay for cutting or removing corns and calluses and clipping or trimming toenails for patients with certain metabolic, neurologic, and peripheral vascular diseases. The Medicare Benefit Policy Manual lists several systemic conditions that might make it medically necessary for podiatrists to provide routine foot care services for these beneficiaries. Along with other conditions, the list includes:
- Diabetes mellitus
- Arteriosclerosis of the extremities
- Chronic thrombophlebitis
- Peripheral neuropathies associated with malnutrition and vitamin deficiency, cancer, multiple sclerosis, traumatic injury, and hereditary disorders
Medicare will also cover routine foot care services when it’s found that part of a foot has been amputated or when the pulse in a patient’s leg or foot is absent and severe swelling, burning, or abnormal sensations appear in the feet. When people wonder why Medicare covers podiatry services for some beneficiaries and not for others, Medicare oversight has cleared up the confusion and unwarranted concerns about fraud and abuse by explaining the four important exceptions to Medicare’s routine foot care exclusion (as discussed above).