Coverage Criteria and Medical Necessity with Medicare

by  Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
March 16th, 2016

In the absence of a systemic condition, treatment of mycotic nails may be covered. The treatment of mycotic nails for an ambulatory patient is covered only when the physician attending the patient's mycotic condition documents that (1) there is clinical evidence of mycosis of the toenail, and (2) the patient has marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

The treatment of mycotic nails for a non-ambulatory patient is covered only when the physician attending the patient's mycotic condition documents that (1) there is clinical evidence of mycosis of the toenail, and (2) the patient suffers from pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

The following metabolic, neurologic, and peripheral vascular diseases (with synonyms in parentheses) most commonly represent the underlying conditions that may justify coverage for routine foot care. Please note, this list is not comprehensive.

-    Associated with malnutrition and vitamin deficiency *

References:

Coverage Criteria and Medical Necessity with Medicare. (2016, March 16). Find-A-Code Spotlight. Retrieved from https://www.findacode.com/articles/coverage-criteria-and-medical-necessity-with-medicare-31610.html

© 2016 innoviHealth Systems (Find-A-Code)

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