Independent Health has updated our Routine Foot Care policy effective September 1, 2015, which will apply to all Independent Health lines of business, except MediSource.
Through August 31, 2015 dates of service, Independent Health will pay for all routine foot care claims with CPT codes 11055, 11056, 11719, 11720, 11721 and G0127 as we have in the past. However, beginning with dates of service September 1, 2015, Independent Health will follow the revised Routine Foot Care policy and claims will be processed according to the CMS Local Coverage Determination (LCD) Routine Foot Care and Debridement of Nails (LCD ID L26426).
In addition, based on the Advanced Beneficiary Notice of Non-Coverage announcement we sent to Medicare Advantage providers on March 25, 2015 (view the notice), providers will need to submit an organization determination for any item or service for a Medicare Advantage member only where a qualifying diagnosis code, according to the LCD, is not listed. Please take note that:
- The organization determination will have to be submitted for medical necessity pre-service.
- If the service is reviewed and deemed not medically necessary, the Medicare Advantage member will receive a Notice of Denial of Medical Coverage (NDMC), along with their appeal rights. Once a denial is issued to the member by the plan for routine foot care, you will then be able to charge the member for the service.
- If a provider does not submit the organization determination request pre-service, the claim will deny to the provider.
If you have Medicare Advantage members scheduled for these services in September, you may begin to submit organization determinations. This submission can also include a treatment plan for future dates of service.
The revised policy (Routine Foot Care), which includes a link to the LCD that contains the list of covered diagnosis codes, is located here.
If you have questions, contact our Provider Relations Department at firstname.lastname@example.org (preferred method) or by calling (716) 631-3282 or 1-800-736-5771, Monday through Friday from 8 a.m. to 6 p.m.