Triple-S considers for routine foot care services when:
· The provider has the proper qualifications.
· The service is considered effective and reasonable according to the condition of the patient described here.
· There is the presence of a systemic condition, whether of a kind:
Metabolic
Neurological
Periferal Vascular
These medical conditions result in circulatory dysfunction or areas of decreased sensation that place the patient at risk by taking care of the foot by a person without professional clinical training.
A Diabetic Neuropathy is evidenced with loss of protective sensation.
The diagnosis must have been established by a physical doctor prior to foot care by the Podiatrist.
In the case of podiatrists, the medical record must have the clinical certification by the physical physician of the pre-existing systemic condition.
Triple-S defines the service of routine foot care as medically necessary in those cases where there are systemic conditions with neurological, peripheral ischemic vascular involvement where:
The patient’s physical physician reports that there is a fungal infection of the nails and that it is of such a nature that it limits the patient’s ambulation, that he has pain or that he has a secondary infection due to the thickening and dystrophy of the finger caused by the nail. In the case of the podiatrist, this documentation must mediate in the medical file. The medical conditions associated with routine foot care are those whose risk ratio may be related to infections, portal of entry or deficiency in vascular healing.
The establishment of the diagnosis of fungal infection or onychomycosis can be established clinically by the Podiatrist or by the physical doctor without the need of clinical pathology services. The KOH test is an integral part of the payment for services in the evaluation and management visit
In cases of policyholders with severe vascular dysfunction, the following documentation is required per class of clinical finding:
Class A:
· Non-traumatic amputation of a foot or a skeletal integral portion
Class B:
· Absent posterior tibial pulse
· Absent pedal dorsalis pulse, or
Three of the following:
· Decrease or absence of healthy growth
· Discoloration or changes in skin pigmentation
· Flushing or redness of the skin
· Changes in skin texture
Class C
· Claudication
· Changes in foot temperature
· Edema
· Paresthesia
· Burning
There will be presumption of coverage in those cases where clinical findings are documented as detailed below. In addition, the modifier should be used as applicable:
On Class A finding èModifier Q7
Two Class B findings èModifier Q8
One Class B finding and two Class C findings èModifier Q9
For cases with peripheral neuropathy without vascular deficiency, the absence of sensation in two (2) or more places of the foot with the monofilament test of Semmes-Weinstein 5.07 should be documented in the medical file, considering that it does not apply to areas of hyperkeratosis or callus, in addition, of any deformity due to trauma, or overload.
Triple S does not consider routine foot care for payment when:
• There is no systemic condition as detailed in the previous section.
• Cut or removal of calluses.
• Treatment of fungal infected nails.
• Nail cutting.
• Foot cleaning and bathing.
• Application of creams.
• Any hygiene modality
