Did you know that 76.4% of improper payments in podiatry are caused by insufficient documentation? According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the podiatry field faces an improper payment rate of 11.2%, totaling over $216 million in projected losses.

One of the most common reasons for these denials is a misunderstanding of the Frequency Period in Podiatry. Medicare and private insurers have strict “clocks” on how often you can perform and bill for specific services. If you bill too soon, you lose money. If you bill too late, you impact patient care.

What is the Frequency Period in Podiatry?

The Frequency Period in Podiatry refers to the specific timeframe required between repetitive services for a claim to be considered medically necessary. For most routine foot care services, Medicare and other major payers follow a strict 60-day rule.

This means that from the date of the last covered service, at least 60 full days must pass before the next service is eligible for reimbursement. Billing even one day early can trigger an automatic administrative denial.

Why Do Frequency Limits Exist?

The Centers for Medicare & Medicaid Services (CMS) implements these limits to:

  • Prevent over-utilization of repetitive Part B services.
  • Standardize care for chronic conditions.
  • Facilitate medical review and lower the volume of submitted bills.

For many podiatrists, the Frequency Period is the difference between a “clean claim” and a “write-off.”

The 60-Day Rule for Routine Foot Care

Routine foot care, including nail debridement, paring of calluses, and trimming of nails, is generally excluded from Medicare coverage. However, exceptions are made for patients with “at-risk” systemic conditions like diabetes or peripheral vascular disease.

Eligible CPT Codes

The 60-day frequency limit typically applies to the following codes:

  • 11720 & 11721: Debridement of nails.
  • 11055, 11056, & 11057: Paring or cutting of benign hyperkeratotic lesions (corns/calluses).

  • G0127: Trimming of dystrophic nails.

The “Active Care” Requirement

For a service to be covered within the Frequency Period in Podiatry, the patient must be under the “active care” of a medical doctor (MD) or doctor of osteopathy (DO). CMS requires that the patient has seen their primary physician for their systemic condition within six months before the podiatry service.

You are paid for what you document, not what you did. Failure to include the primary physician’s NPI and the “last seen date” on the claim is a leading cause of frequency-related denials.

Beyond the 60 Days: Other Frequency Limits

While the 60-day rule is the most famous, other podiatric procedures have different “clocks” that billers must track.

1. Mycotic Nails and Debridement

Medicare may cover debridement of mycotic nails (fungal nails) even without a systemic condition if the patient experiences pain or secondary infection. However, the Frequency Period for these services in podiatry remains once every 60 days.

2. Surgical Global Periods

If a podiatrist performs a surgical procedure, the “frequency” is dictated by the global period.

  • 0-Day Global: Minor procedures (e.g., some biopsies).
  • 10-Day Global: Minor surgeries (e.g., nail avulsion CPT 11730).
  • 90-Day Global: Major surgeries (e.g., hammertoe repair CPT 28285).

During these periods, follow-up visits related to these procedures cannot be billed separately. Doing so violates the frequency and bundling rules.

3. Chronic Disease Management

In some regions, such as under the Medicare Benefits Schedule (MBS), patients are limited to five allied health sessions per calendar year for chronic conditions. This creates a different type of frequency cap that requires careful coordination with the referring GP.

Comparison of Common Podiatry Frequency Limits

To help your billing team, refer to this table for the most common frequency and global period limitations based on CMS Guidelines.

Service Category CPT Codes Typical Frequency Limit Key Requirement
Routine Foot Care 11721, 11055 Once every 60 days Q7, Q8, or Q9 Modifiers
Nail Avulsion 11730 10-Day Global Same toe: 8-month limit (some payers)
Hammertoe Repair 28285 90-Day Global Includes all related post-op care
Wound Debridement 11042 Based on necessity Documentation of wound size/depth
New Patient E/M 99202–99205 Once every 3 years Patient must be “new” to the practice

Documentation for Frequency Compliance

To successfully bill within the Frequency Period in Podiatry, your SOAP notes must be bulletproof. A standard note should include:

  • Subjective: Patient’s specific complaints (e.g., “pain while walking”).
  • Objective: Physical findings, such as Class A, B, or C findings for at-risk patients.
  • Assessment: The specific diagnosis (e.g., E11.621 for Type 2 diabetes with foot ulcer).
  • Plan: The treatment performed and the justification for its frequency.

The Role of Modifiers

Modifiers are the “language” used to tell payers why a service should be paid despite frequency rules.

  • Q7, Q8, Q9: Indicate the severity of the systemic condition (Class Findings).
  • Modifier 25: Used when a significant, separately identifiable E/M service is performed on the same day as a routine procedure.
  • Modifier 59: Used to identify distinct procedural services performed on different sites.

Common Pitfalls and How to Avoid Them

Even seasoned practitioners struggle with the Frequency Period in Podiatry. Here are the most common errors that lead to revenue loss:

1. The “Day 59” Denial

Scheduling a patient exactly 60 days after their last visit is risky. If the last visit was January 1st, the next eligible date is March 3rd (in a non-leap year). Many practices are scheduled at 61 or 62 days to provide a safety buffer.

2. Missing Primary Care Data

For routine care, you must include the MD/DO’s NPI who is treating the patient’s systemic condition. Without this, the payer assumes the “active care” requirement hasn’t been met.

3. Overlooking Payer-Specific Rules

While Medicare sets the standard, private insurers may have different “clocks.” Some may limit nail debridement to four times per year, regardless of the 60-day window.

4. Failure to Use ABNs

If a patient requests a service before the Frequency Period in Podiatry allows, you should issue an Advance Beneficiary Notice (ABN). This informs the patient that Medicare likely won’t pay, and they will be financially responsible.

Streamlining Your Revenue Cycle

Managing the Frequency Period in Podiatry manually is a recipe for burnout. Modern practices use Electronic Health Records (EHR) with built-in “hard stops.” These systems alert the front desk if a patient is being scheduled too early.

Additionally, outsourcing to a specialized podiatry billing service can reduce your denial rate. Experts who understand the nuances of the 60-day rule and the required Q-modifiers can ensure your claims are paid on the first submission.

Protect Your Practice’s Bottom Line

Handling the Frequency Period in Podiatry requires a mix of clinical precision and billing expertise. By respecting the 60-day rule, meticulously documenting class findings, and using the correct modifiers, you can significantly reduce claim denials.

Remember, an efficient billing process doesn’t just save money; it allows you to spend more time focusing on patient outcomes. Don’t let administrative clocks drain your practice’s resources.

Stop losing revenue to frequency denials.

At Billing Podiatry, we specialize in the complex world of podiatry coding. Our team ensures that every claim meets the strict frequency guidelines set by CMS and private payers, helping you maintain a healthy cash flow.

Contact us today to optimize your podiatry revenue cycle!

Frequently Asked Questions

1. Does the 60-day rule apply to the whole foot or each toe?

The 60-day rule applies to the entire routine foot care visit. You cannot bill for nail debridement on the left foot today and then bill for the right foot 30 days later. Medicare views routine foot care as a single service session for both feet.

2. What happens if a patient has an emergency before the 60 days are up?

If a patient has an acute issue, such as an infected ingrown nail or a new ulcer, this is not considered “routine foot care.” You can bill for medically necessary treatment regardless of when the last routine visit occurred.

3. Can I bill an E/M code during a routine foot care visit?

Generally, no. Medicare does not allow a separate Evaluation and Management (E/M) code if the only purpose of the visit is routine foot care. You can only bill an E/M (with Modifier 25) if the patient presents with a new, unrelated problem.

4. Is the 60-day clock based on “calendar days” or “business days”?

The Frequency Period in Podiatry is based on calendar days. You count exactly 60 days from the date of the previous service. The date of the previous service is “Day 0.”

5. How do I bill for a patient with “Presumption of Coverage”?

Presumption of coverage is granted when a patient has specific physical findings (Class Findings) indicative of severe peripheral involvement. You must document Class A, B, or C findings to justify the frequency of care.