Educating Aging Adults About Medicare Coverage Of Podiatry Services

Just as we know we can treat anything in the foot and ankle from ingrown toenails to plantar fasciitis to complex fractures, we know aging adults are prone to chronic foot problems, especially if they have an underlying disease such as diabetes. We also know that Medicare doesn’t cover all podiatry services. 

Medicare has specific rules for coverage, based on the patient’s diagnosis and proposed treatment. Communicating this to patients begins with understanding the rules ourselves. We can then formulate a plan to educate our patients on these guidelines, which will help them understand why we make certain decisions. It will also enlighten them as to how we can help them and loved ones now and in the future.

Medicare doesn’t cover routine foot care except in situations in which another health condition requires it and class findings (such as diabetic neuropathy) are met. It may be of benefit to incorporate this information into your initial patient exam. By showing a patient that he or she does not indeed meet these class findings, the patient has concrete information that shows why it is not a covered service. This could then be followed by an Advance Beneficiary Notice (ABN) for the non-covered service should the patient choose to proceed with routine foot care. Often, the patient may have been told something different by a previous provider and it helps to be able to show the patient your reasoning in black and white. Careful documentation of class findings and associated requirements, such as a last medical visit with the primary care physician, when necessary, is essential.

Medicare also doesn’t cover supportive devices, such as orthopedic shoes, unless they are included in the price of a leg brace or when the patient has diabetes. Even when the patient has diabetes, there is a specific algorithm that determines eligibility for this service and it may not include every patient with that diagnosis. Including the patient in the discussion and evaluation for eligibility will go a long way in the patient committing to the treatment plan you are proposing. Many patients with diabetes erroneously assume they are entitled to “free shoes” when we all know the benefit and selection of such a treatment is much more complicated than that.

Medicare will cover podiatry services that are considered necessary to diagnose or treat a medical condition. Conditions such as hammertoes, heel spurs and bunion deformities yield Medicare coverage for treatment in the form of an evaluation and management visit. However, it is important for the patient to know how you are planning to evaluate him or her and what to expect when it comes to coverage. Medicare Advantage plans specifically may require referrals or authorizations for certain services, such as X-rays. The patient may not be aware of this. Having your staff take the time to check benefits and letting patients know what is required will likely lead them to have confidence in your practice instead of them getting a “surprise” bill later on.

Patients with diabetes may qualify more clearly for serviceswhen it comes to foot care because they have a greater risk of developing foot conditions. However, it is very important for them to understand the role of the podiatrist in their overall health and wellness. They should be seeing the doctor (primary physician or endocrinologist) treating their diabetes within six months of their podiatry visit. It is shocking that this is not routine for some patients with diabetes, but we have the opportunity to educate them and encourage them to follow up with HbA1c testing, and other important maintenance. This is obviously in addition to the comprehensive education we provide as part of their foot exam.

Mycotic nails can be common in the podiatric patient community. Medicare may cover treatment for mycotic nails if there is documented clinical evidence of infection, and you are showing symptoms such as pain or secondary infection. Guidelines are evolving for this service so check the local coverage determination (LCD). However, you may want to consider fungal culture to document said clinical evidence and using this as an educational tool for your patients. It will allow you to explain how treatment works, or, if there is indeed no fungus involved, it will allow productive discussion of alternative diagnoses and treatment.

Helping Patients Understand How Medicare Pays For Podiatry Services

Since one usually performs podiatry services in an outpatient setting, Medicare Part B applies. Medicare Part B will pay 80 percent of covered medical costs. The patient is responsible for both an annual deductible and 20 percent of the bill. Many patients are not aware of the yearly deductible and are shocked when receiving their invoice. Taking the time to educate patients, whether through postings in your office, an office policy that they sign or by a brief conversation with staff, will save time and tension in the future.

If the patients ever require surgery to treat a foot condition and are admitted to the hospital as inpatients, Medicare Part A will come in effect as well. A larger deductible applies here as does the 20 percent co-insurance. This deductible also covers the first 20 days in a skilled nursing facility (SNF) if it is recommended that the patient finish recovery there. Medicare will only cover the SNF stay if the patient was admitted to the hospital for at least three days. 

When a patient applies for Medicare, he or she may ask you what plans you recommend. Although this varies wildly by region, the patient may want to consider supplemental coverage to help pay for things traditional Medicare does not. Medicare plans such as Medigap and Medicare Advantage can help lower some of these costs. Medigap plans can help cover a patient’s Part A deductible and Part B deductible, copays, and coinsurance. Medicare Advantage plans can help lower a patient’s out-of-pocket costs by setting a copayment amount that may be lower than a patient’s normal Part B coinsurance. Medicare Advantage plans also may offer extra podiatry services, such as routine foot care exams. Simply explaining the difference between a Medigap policy and a Medicare Advantage policy may make all the difference to your patient who is overloaded with confusing information about insurance.

In summary, using your knowledge about Medicare and related insurance may help you retain current patients and gain future ones. The confusing and complex aspects of insurance coverage may pose a barrier to the doctor-patient relationship. Building a reciprocal conversation will allow for less surprises for both you and the patient. Committing even a short amount of time toward educating patients on these issues will foster confidence in your knowledge in and out of the treatment room.

Dr. Blake is in practice at the Center for Sports Medicine affiliated with St. Francis Memorial Hospital in San Francisco. He is a past president of the American Academy of Podiatric Sports Medicine.

Editor’s note: This blog originally appeared at www.drblakeshealingsole.com. It is adapted with permission from the author.